Based on over 20 years of success, Nuance’s Clintegrity® CDI is a proven, fully managed end-to-end clinical documentation improvement program backed by the J.A. Thomas Compliant Documentation Management Program® (CDMP®) that touches all the critical aspects of your institution's clinical documentation process. Our services and technology help you achieve an Advanced Practice CDI™ program, one that ensures high quality documentation in all care areas in your healthcare system, coordinating the efforts of your clinicians and improving quality across the continuum of care. Beginning with an initial assessment of your records and documentation needs, our team of experts will help you identify clear, measureable objectives for your CDI program. We will help manage every aspect of implementation from customizing and integrating the technology tools to ensuring your physicians, nurses, coders, and administrators understand the program and are successfully using it. Nuance will work with you to continually monitor and manage the program to make sure it meets the objectives your organization has set.
Nuance’s Clintegrity CDI is a premier clinical documentation improvement program backed by the J.A. Thomas Compliant Documentation Management Program® (CDMP®), with a fully managed, end-to-end improvement program that touches all the critical aspects of your institution's clinical documentation process.
Clintegrity CDI normally pays for itself in a matter of months as it helps you:
Unlike retrospective coding-based programs, Clintegrity CDI gives doctors and nurses education, strategies, and tools that allow them to accurately document each case from the moment a patient enters the hospital.
Our program gives you a concurrent, clinical process that accurately captures compliant documentation language, complexity levels, and severity levels and ensures that they are reflected appropriately in your Case Mix Index.
All our documentation strategies are fully compliant with The Coding Clinic and ICD-10 Official Guidelines. With Clintegrity CDI, every record contains the compliant language necessary to support appropriate reimbursement and avoid the loss and risk associated with non-compliance.
Clintegrity CDI Quality helps you identify cases subject to quality core measures in real time and impacts and improves core measure reportable data, enhancing your competitive positioning.
The more complex and severe diagnoses you manage, with appropriate documentation, the higher your CMI. And the higher your CMI, the better your reimbursement. Clintegrity CDI maximizes appropriate reimbursements by improving your documentation. It also protects you against the risk of RAC audit liability.
Healthcare reform has resulted in fewer people being treated in an acute care hospital setting in favor of lower-cost outpatient or ambulatory settings. It also directs that reimbursement for patient care be tied to quality or a value-based model, rather than the traditional fee-for-service structure.
Government officials are accelerating the shift from volume to value-based payments with a goal of building a healthcare delivery system that improves quality, affordability and access to care. This shift requires health system financial leaders to manage novel and increasingly complex care delivery and payment models while straddling between two disparate payment systems.
Healthcare executives must rethink their approach to clinical documentation improvement (CDI) to effectively address these challenges and mitigate the risks and costs that can result if they fail to protect revenue – and patients – by overlooking the significance of quality documentation.
Drawing on more than 20 years of clinical documentation expertise, Nuance’s J.A. Thomas & Associates (JATA) approach to Advanced Practice Clinical Documentation Improvement™ spans across the care continuum including physician offices, hospital outpatient departments, and ambulatory surgery/care centers. Our comprehensive ambulatory consulting services provide an end-to-end approach touching all critical aspects of clinical documentation, coding and billing processes to ensure compliance and revenue integrity.
We understand CDI in the ambulatory setting is complex. But the rewards of taking on this challenge are critical, not only improve CDI, but to assure compliance and revenue integrity. Our team provides expert consulting services in each of the following areas and to guide your journey.
Getting the assessment right is key to clinical documentation improvement. That's why we kick off every project with a 3-4 day clinical evaluation. We bring in a team of clinical and coding professionals to study a statistically significant sampling of your DRG-based records. They closely evaluate how admissions are being categorized according to diagnosis-related groups.
We also bring in our own physicians to meet with key members of your medical staff. They explain how the program works and make the clinical case for Clintegrity CDI to these members. Our physicians address what the expectations are, how the program benefits doctors, and how Clintegrity CDI helps improve performance measures. This way, physicians clearly understand the program from the very beginning.
With a proper assessment in place, we can accurately project the impact our Clintegrity CDI program will have on your CMI. Using these projections, we can guarantee the results of the program. This gives you a clear picture of the project outcomes before the implementation even begins.
Implementing Clintegrity CDI is an in-depth process. That's why we work closely with you through every step. Our Clintegrity CDI team comes on site to help put the program in place and guide you through the entire implementation. Here's a brief overview of what's involved.
We provide the tools, templates, best practices, and everything else needed to prepare for a smooth and successful implementation. This includes on-site and off-site guidance and discussion to customize your program, as well as hands-on assistance with testing and interviewing as you hire your Clinical documentation improvement team.
Our physicians, nurses, and coders work directly with yours to ensure an effective skills transfer. We provide clinically relevant examples and on-the-floor clinical rotations where our experienced professional staff model the Clintegrity CDI process. We educate all relevant team members on the use of our Clintegrity CDI software and tools.
Using clinically relevant examples in the hospital and in your doctors' offices, we clearly demonstrate to your physicians how each of them can personally benefit from learning and practicing Clintegrity CDI. Our physicians and Part B experts also provide tailored education for large and small groups.
We work closely with your hospital's Clinical Documentation Specialists and HIM Coders to educate them on our 720+ documentation strategies. This involves a combination of formal classroom education and hands-on training. We demonstrate the outstanding results of Clintegrity CDI through multiple clinical rotations, giving your team a solid understanding of how clinical documentation improvement leads to improved CMI.
We provide state-of-the-art tools and technology, to leverage your team's clinical intuition and support proper documentation. Developed by practitioners, our software is continually updated with the latest documentation strategies and Coding Clinic guidelines. It enables your team to concurrently capture quality core measures and appropriate levels of severity, and enables real-time tracking against best-in-class benchmarks. We also provide other tools, templates, manuals, and pocket guides customized by specialty and roles as needed.
We maintain constant, close monitoring to ensure that the program is being implemented successfully and is delivering results according to plan. This helps to keep everyone on the same page and avoids surprises along the way.
We stay closely involved after the implementation has been completed to ensure the sustainability of the program. This includes ongoing monitoring, continuing education, and regular evaluation and adjustment. We make sure your physicians and Clinical Documentation Improvement team stay up to date with the latest regulatory guidelines as well as the newest strategies for documentation improvement.
As more and more patients are admitted through your Emergency Department, accurate documentation is becoming critically important. Due to the complexity of ED cases, the hectic work environment and the need to make rapid decisions, in many cases patient acuity is inaccurately reflected by under-documentation of the patient's clinical situation. Staff may accurately document the injury that brought the patient in, but miss secondary diagnoses and/or pre-existing conditions. What's more, a problem list isn't usually created until the patient is moved onto the floor...if ever. Improving the quality of the clinical documentation promotes better communication and creates an opportunity to positively impact clinical outcomes.
Nuance has developed a powerful solution and a new clinical staff position to help you ensure better clinical outcomes and accurate reimbursement.
Because documentation of critical information starts in the Emergency Department, the Point of Entry program starts there too - evaluating the severity of illnesses, assessing present-on-admission (POA) conditions, determining patient status (observation or inpatient), ensuring compliance with quality core measures, creating a problem list at the point of entry, and enabling more accurate documentation. The Point of Entry program builds on the foundation of Clintegrity CDI; and takes it even further, providing comprehensive clinical integration management.
With this new solution comes a new clinical role - the Clinical Integration Specialist (CIS). This individual works closely with your clinical team to ensure all clinical observations are documented appropriately from the ED to discharge.
In this webinar replay, see how clinical quality outcomes data (pre- and post-CDI implementation), provide insight into the value of measuring CDI efforts' impact on overall quality ratings, including expected mortality and inpatient quality indicators.
In our On-Demand webinar, “Initiatives That Drive Quality Performance and Financial Reimbursement,” Angie Curry, Corporate CDI Manager at CoxHealth, discusses how to build a successful CDI program.
The On-Demand Webinar addresses clinical documentation challenges and aims to mitigate the risks and costs that can result if providers fail to adopt effective Ambulatory CDI programs.
When it comes to the role of the physician advisor in CDI, there’s room for improvement, according to the 2016 ACDIS Physician Advisory Survey.
Report findings are based on surveys from 100+ healthcare leaders with key CDI strategies for managing the transition from volume-cased to value-based care.
Nuance ranks top vendor in consolidated solutions category for CAC, CDI, coding, speech recognition and transcription.
Nuance ranks #1 second year in a row on 13 of the 18 criteria in the study.
This article highlights the differences between inpatient and outpatient CDI programs and explains how a robust Ambulatory CDI program can help mitigate risk and prepare your organization for value-based payment methodologies.
Clintegrity will help your organization quickly generate substantial revenue and operating savings by ensuring your clinical documentation chain is accurate, sound and fully adopted by physicians.