Welcome to Lesson 4 of CAHPS PCI Registry, Metric No. 45, Cardiac Rehabilitation Referral, where we will review the finer points of Metric 45 and how it operates, introduce smart phrase terminology that meets the definition and target value for coding YES to Sequence 10-116, and lastly, familiarize participants with resources for improving metric performance that are currently available on the QII website. The Cardiac Rehabilitation Referral Measure, Metric 45, is one of several new guideline-directed measures that have been added with the introduction of the Version 5 dataset, launched in the second quarter of 2018. The data on cardiac rehab effectiveness and relatively low utilization illustrates why that is. Cardiac rehab services have been shown to help reduce morbidity and mortality in persons who have experienced a recent coronary artery disease event, but these services are used in less than 30% of eligible patients. A key component to cardiac rehab utilization is the appropriate and timely referral of patients to an outpatient cardiac rehab program. This performance measure has been developed to help healthcare systems implement effective steps in their systems of care that will optimize the appropriate referral of a patient to an outpatient cardiac rehab program. Metric 45, Cardiac Rehabilitation Referral, reports the percentage of patients who receive a cardiac rehab referral after PCI. The numerator is met any time an eligible patient receives a cardiac rehab referral to meet the definition and target value during the episode of care, and yes is coded in Sequence 10-11-6. The denominator is made up of all patients that received PCI, either attempted or successfully performed, supporting yes to be coded in Sequence 70-50, PCI. Metric 45 contains important denominator exclusions that effectively remove certain patient populations from the metric denominator. Denominator exclusions remove a patient from the eligible metric population when any of the following conditions hold true. The patient is ordered to receive comfort measures only. The patient dies during the hospitalization. The patient leaves against medical advice. They are discharged to another acute care facility, or the patient is discharged to hospice. Metric 45 also contains important denominator exceptions that effectively remove certain patient populations from the metric denominator. Denominator exceptions remove a patient from the eligible metric population when the patient has not met metric numerator criteria and there is acceptable rationale provided. In this case, either a medical or healthcare system reason for why a cardiac rehab referral was not provided. Essentially, when either a denominator exclusion or exception is met, the net result is the same. The patient is removed from the denominator of the metric. We are now going to revisit each case scenario discussed in Lesson 3 of this course and examine how metric performance is impacted. In the first case scenario, a patient received PCI on a Saturday, was discharged on a Sunday, and the cardiac rehab referral order was carried out the following day on Monday. No reason not documented was coded in Sequence 10-116 as the target value, value on discharge, was not met. Regarding metric 45, we know that PCI was performed and therefore the patient was eligible, but the measure was not met. As denominator exclusion exception criteria was also not met, we find that the patient is included in the denominator but not included in the numerator. In the second case scenario, a patient received PCI, cardiac rehab was ordered, and there was a documented attempt to inform and discuss cardiac rehab options with the patient, but the patient declined. The documented attempt and patient refusal supports coding yes in Sequence 10-116. For metric 45, we know that PCI was performed, the patient was eligible, and the measure was met. Denominator exclusion exception criteria was therefore not applicable, and we find that the patient is included in both the denominator and the numerator. In the third case scenario, a patient received PCI and was discharged the following day. The provider documented that the patient's PCI was unsuccessful and that cardiac rehab was not indicated. No reason not documented was coded accordingly in Sequence 10-116. With respect to metric 45, we know that PCI was performed and the patient was eligible, but the measure was not met. Denominator exclusion exception criteria was not met either, and the patient is therefore included in the denominator but not included in the numerator. In the fourth case scenario, a patient received PCI and refused to follow the post-procedure protocol and ultimately left the hospital against medical advice. No reason not documented was coded accordingly in Sequence 10-116. Regarding metric 45, we know that PCI was performed and the patient was eligible, but the measure was not met. Denominator exclusion exception criteria, however, was met as the discharge status of AMA or against medical advice qualifies as a denominator exclusion. The patient is therefore excluded from the metric entirely and not included in the denominator or the numerator. In the fifth case scenario, a patient had recently received PCI, was already enrolled in an outpatient cardiac rehab program, and has now returned for a staged PCI of another vessel. Provider documentation of the patient's current enrollment and plan to continue participation supports coding yes in Sequence 10-116. For metric 45, we know that PCI was performed and the patient was eligible and the measure was met. Denominator exclusion exception criteria was therefore not applicable, and we find that the patient is included in both the denominator and the numerator. In the sixth and final case scenario, a patient undergoes unsuccessful PCI and agrees to return in a subsequent episode of care for bypass surgery. The physician documents that cardiac rehab is not indicated until after the patient has their bypass surgery due to severe CAD and risk of ACS, which supports coding no, medical reason documented. With respect to metric 45, we know that PCI was performed and the patient was eligible, but the measure was not met. Denominator exclusion exception criteria, however, was met as a medical reason for not providing a cardiac rehab referral qualifies as a denominator exclusion. The patient is therefore excluded from the metric entirely and not included in the denominator or the numerator. Metric 45 cardiac rehab referral metric performance is available by visiting the cath PCI e-reports dashboard. Patient drill down details are available for a given quarter by selecting patient detail and additional metric performance results are available such as performance among comparison groups by selecting metric detail. Cardiac rehab referral EMR smart phrases. Smart phrases are blocks of text that can be copied, pasted, or clicked into your hospital's electronic health record system to automatically create discharge papers for common emergency room presentations. The use of smart phrases has proven to be a time saver in documentation. Smart phrases have also provided a method for more standardized documentation. They aid providers in including pertinent information necessary to demonstrate the decision-making process and plan of care for treating patients. The success of using smart phrases has spread to other disciplines such as nursing and rehabilitation services. Key ingredients of a cardiac rehab referral smart phrase are comprised of all necessary components of the data definition in sequence 10116, including written documentation of the referral, the provision of all necessary information including cardiovascular history, and relevant testing and treatments, as well as evidence of communication of this information to the cardiac rehab program either by the facility or the patient themselves. An example of a cardiac rehab referral smart phrase that satisfies the requirements for coding yes in sequence 10116 and an example of a health care facility that communicates directly with the cardiac rehab program might look like the following. Cardiac rehab ordered and benefits reviewed with patient referral provided to the patient at discharge to an early outpatient cardiac rehab phase two program. Necessary patient information communicated to the cardiac rehab program. The first appointment has either been made or the patient has been provided with contact information to make this appointment. An example of a cardiac rehab referral smart phrase that satisfies the requirements for coding yes in sequence 10116 and an example of a process in which the patient is provided the necessary information and communicates directly with the cardiac rehab program might look like the following. Cardiac rehab ordered and benefits reviewed with patient referral provided to the patient at discharge to an early outpatient cardiac rehab phase two program. Patient provided with necessary referral information relevant history and instructed to bring to the cardiac rehab program on first visit. The first appointment has either been made or the patient has been provided with contact information to make this appointment. We'd like to direct you to some valuable resources available at the QII site by visiting cbquality.acc.org. Quality campaigns and clinical toolkits are available to assist you in driving quality improvement for outpatient cardiac rehab referral as well as other programs. The hospital to home or h2h initiative is a resource for hospitals and cardiovascular care providers committed to improving transitions from hospital to home and reduce their risk of federal penalties associated with high readmission rates. There are three self-contained improvement projects to select from each including a goal statement, success metrics, a toolkit, assessment, and webinars focused on evidence tools and lessons learned. These provide participants with recommended strategies and resources to achieve small attainable goals in their organizations. CUN7 is specifically geared toward patients discharged with a diagnosis of heart failure or acute MI with the objective of having an appointment scheduled or cardiac rehab referral made within seven days of a patient's discharge from the acute care setting. Assessments provide benchmarking data and are designed to identify opportunities for improvement. Toolkits provide resources and strategies designed to address one general topic area for improvement. Listen to an on-demand webinar that reviews evidence-based toolkits and lessons learned. Collaborate and interact with others on the listserv who share best practices and lessons learned. Read how others are implementing best practices. This concludes lesson four of CAP PCI Registry metric number 45 cardiac rehabilitation referral where we reviewed the finer points of metric 45 and how it operates, introduced smart phrase terminology that meets the definition and target value for coding yes to sequence 10116, and lastly, familiarized participants with resources for improving metric performance that are currently available on our QII website. Thank you for your participation.

CAHPS PCI Registry

Cardiac Rehabilitation Referral

Patient outcomes

Smart phrases

QII website