Percent of Patients with Pressure Ulcers That Are New or Worsened (M1311, M1313)

Percent of Patients with Pressure Ulcers That Are New or Worsened (M1311, M1313)


»» Hi everyone. Good morning. Hopefully you had a nice break. Welcome to those of you who are viewing from
your offices or from home. Just a couple of housekeeping things before
we get started. When you ask a question, when we get to the
point of Q&A, if you could come up to the microphone. The reason for that is, although you may speak
loudly and we can hear you here, the people that are watching from their offices or on the
livestreaming really can’t hear the questions. So if you can, you know, go up to the microphones
that would be great. For those of you that are in the room, your
clickers, there seems like there’s some confusion. So when we get to polling questions, discuss
at your table. One person pick up the clicker or the polling
devices. And all you need to do is hit, I think almost
all of our questions are A, B, C and D. So just choose either, A, B, C or D as far as
the answer. You don’t need to hit send or anything. If you hit A and you go Oh shoot, I meant
to hit B. Go ahead and click B and it will change your answer. That’s it for the clicking device. As Mark, said we are going the use the folder
Number 4. I just want to review a couple of things that
are in that folder. If you can have kind of readily available,
and for those of you in the room, some of these things are in your folder. We have — we’re going to be doing an activity
called the scavenger hunt. So there’s a scavenger hunt handout. And then we will be using a pressure ulcer
scenario coding sheet. So if you can have those readily available
to you. Just a reminder that as we go through this,
what you have posted will not have the answers when you pull this down from the web, will
not have all the answers in it. Because then that’s giving you the answers
to the activity. But once we finish all of this training, the
materials with the answers will be posted. And the idea behind that is then you can use
that when you — within your organizations for staff training. To today we’re going to talk at the percent
of residents with pressure ulcers that are new or worsening and the associated OASIS-C2
items. And so of course we always start out with
some objectives. We’re going to start and look at the numerator,
the denominator. What are some of the denominator exclusions? What are the measurement timeframe and windows,
some of the QM calculation algorithms, the risk adjustments. Then we actually will go through some of the items and we’ll do some practice scenarios around coding
or scoring those particular items. We hope that by the time that we complete
these sessions, we’ll have this session, take a break for lunch. Then I’ll follow up with the conclusion of
these materials, that you’ll be able to describe the intent of 1311 and 1313 and interpret
the response options for 1311 and 1313 and then ultimately apply the instructions in
order to accurately respond to the practice scenarios. And in fact, just use it in your practice. So I wanted to just start off talking about
this term “code.” You’ll hear me use the term code or coding
the OASIS. And we wanted to make sure that everyone,
so we had kind of this shared mental model. Everyone understood what we’re talking about. That when I’m talking about code or a coder,
I’m not talking about a coder in your office that’s maybe doing ICD-10 coding. This is about actually completing the assessment,
coding the items. So I just want to make sure that there’s no
confusion about terminology. So throughout my session when I talk about
coding the item, I’m not talking about a coder. I’m not talking about the ICD-10 coding. I’m talking about coding the correct response
accurately, indicating the correct response on the item set. All right. So the percent of residents or patients with
pressure ulcers that are new or worsening, we’re going to be talking about this QM. What we’re looking about here, it’s adopted
as a cross-setting measure to meet the requirements of the IMPACT Act. So you’ve already started to hear this. You heard this from Stace Mandl. You’ve heard earlier about this. And the idea here is you need to understand
what we’re trying to do is across all the post-acute setting, nursing homes, home health
with the OASIS, inpatient rehab facilities and long-term care hospitals, what we’re trying
to do is have these measures look the same, be coded the same. So now we can start to understand the quality
of care in each one of the setting and then measuring that quality across all of the settings. And so, we’re — with this particular measure,
it’s intended to encourage post-acute care providers to prevent pressure ulcers. Although I think that that’s — we’re all
trying to prevent pressure ulcers or worsening of them and to closely monitor and appropriately
treat existing pressure ulcers. But it gives us a sense, and we’ll be able
to measure as you — we’ll be able the measure when you look at apples to apples versus apples
to oranges. So they were similar, if you took, kind of
some of the definitions from the as MDS compared to the OASIS they were similar but not exactly
the same. And then some of the other settings we really
weren’t looking at this all or having to report it. So now of a sudden, we’re trying to align
all of these measures and have them be the same. So that’s the reason, depending on the setting
that you’re working in, it maybe a totally new item for you, or it’s a tweak or an adjustment
to a particular item. So that gives you the idea behind that. So the quality measure description, it reports
the percent of patients with a stage 2-4 pressure ulcer present at discharge, that are new or
worsened since the beginning of the quality episode. And we talked about defining the quality episode
as the pairing of the start or resumption of care, so the SOC or the ROC assessment
with the end of care assessment. And the measure is calculated using data from
of course the OASIS. So what I want to do is, we’re going to start
off. You’ve had a lot of activity this morning. We had a good break. But I want to spend about 10 minutes, and
we’re going to do an activity that we’ve used in some of our other trainings. And we call this the scavenger hunt. So for those of you who are watching this
livestream, if you can pull out your scavenger hunt slide deck. And it looks something like this. Hopefully you can see this at home. For those of you here, you have have a nice
color copy of it in your folders. And what you’ll notice, it’s two slides per
page. And we’ll go through there. And there’s some blanks in there. There are actually nine blanks that you’re
going to fill in. And how are you going to get this information? Well, on your tables are this thing called
the Home Health Quality Reporting Program Specifications for Cross-Setting Quality Measures. For those of you watching this livestream,
that’s in that folder Number 4. You can pull that out. To do this activity you need your scavenger
hunt slides and you need your technical specifications. We put this activity in specifically because
often when we go out, we work with organizations and/or we’re doing trainings, most staff don’t
understand, well what data elements go into this? Or how does this measure? What is the ultimate — Why am I doing poorly
in this particular measure? What questions am I answering on the OASIS
that are feeding into that? What’s in the numerator? What’s in the denominator? I don’t understand. How do things get excluded? So this is an activity that forces you to
search through this document and find the answers. And what you’ll find is, this is a very valuable
document. Not only will you use it for this measure,
but for each one of the other reporting measures that come out there will be a technical specification
document. The idea is then you’ll say, well, oh gosh. I know what is. Let me go into the document for that particular
measure. Now I know that I can look for the definitions
for the numerator, and the denominator, and the exclusions and whatnot, and how the calculations
are done. So what I would like to do is everyone prepare. Hopefully in your offices on streaming live,
and for here, hopefully I’ve given you enough time to pull out your documents. What I’d like you to do is work — you can
with work as teams. This is not a solo event. If you’re watching livestreaming, hopefully
you have a partner or two in the area that you are watching this from. Pull out these. And actually go through and start discussing
and looking for these particular items. So answering the blanks in each one of these
slides. So I’m going to give you about 10 minutes
to do that. I’ll keep an eye on the room here. And so for you watching live, we’re going
to start this activity now. And we’ll start back by my watch in about
five after. So why don’t we go ahead and start this scavenger. All right. How was that activity? Good? Good? Hopefully for those of you in livestreaming
that you found some value in that. I strongly encourage you to read through that
document and get familiar with it. But let’s go through some of the answers. Okay. So our first question we have is the percent
of residents or patients with pressure ulcers that are new or worsening. And we were looking at the numerator. And it’s the number of patients with a…
complete quality episode for which the assessment was completed at the end of care. Alright. And then the denominator we have there is
the number of patients with a complete quality episode except for those who meet the exclusion
criteria. All right. So the next one that we have is, new or worsened
pressure ulcers are determined based on examination of all assessments in the patient’s quality
episode for reports of stage 2-4 pressure ulcers that were not present or were at a
lesser stage on the SOC or ROC as evidenced by — and then we have the coding here. So we’re starting to go through kind of all
of the components that are built into your quality reporting. So you have — let me go back. We have the numerator, which we talked about. So it’s looking at the complete episode. And then the denominator is all those, except
for if you are excluded. Oops. Sorry. All right. So again, new or worsened are the stage 2-4. And we’re looking at the SOC/ROC as evidenced
by having a stage 2, 3 or 4, greater than 0. All right. So let’s look at the denominator. So patients that blank while on service with
a home health agency are excluded from this measure as they would not have completed a
quality episode? Right. Okay. And then patients without an assessment completed
at the start of the resumption of care and an assessment completed at the end of the
care excluded, and patients are excluded if none of the assessments has a usable response. So always you’ll see that caveat. If we don’t have the data in there that are
used to calculate the quality measure reporting it can’t be used. So some of the quality measures included in
the quality episodes that end with a discharge, transfer or death, the new or worsened pressure
ulcer measure utilizes data from M1313, which is collected only at discharge. Therefor, episodes ending in transfer to an
inpatient facility or death at home are not considered for this particular measure. So that’s a caveat for this particular measure
here. Hopefully that will help clarify that denominator
measure. So measure time window, it’s calculated blank
using rolling 12 months of data? Quarterly. Correct. All complete quality episodes except for those
that meet the exclusion criteria during the 12 months will be included in the denominator
and are eligible for inclusion in the numerator. And for patients with multiple episodes during
the 12-month time window, each episode is eligible for inclusion in the measure. So you may have a patient or client with multiple
episodes being included. All right. And then the measure is risk adjusted based
on the patient characteristics or covariates. We’re going to go into a little bit about
that. And patients with characteristics or conditions
that put them at an increased risk for skin breakdown or impact their ability to heal
are treated differently in the measure calculations. So that makes sense, right? So if I have — if I’m at higher risk for
skin breakdown versus, let’s say if I’m immobile and incontinent and a variety of other things,
versus someone who’s up and about and walking, we would think that their chance or risk of
having a pressure ulcer would be less. And then risk adjustment is used to account
for the medical and functional complexity of the patients. So it’s trying to even or level-out the various
types of patients that we have and putting risk involved. So let’s talk a little bit about risk adjustment
covariates. Indicator of supervision/touching assistance
or more at the SOC or the ROC for functional mobility item blank? Okay. And then let’s go through and finish answering
these questions. Okay. So sitting — item in lying to sitting on
side of bed. So that’s that item GG0170C. And that will go through that a little bit
later on today. Indicator of bowel incontinence at least occasionally
on the initial assessment. So these are again some of the covariates
or risk adjusters. They have diabetes mellitus blank or peripheral
arterial disease? Peripheral vascular disease. And that makes sense to us, right, clinically
for those of you that are clinical here. So that makes sense. And indicator of low Body Mass Index based
on height, which is M1060a, and weight M1060b (or 1-0-6-0-b, sorry) on the SOC or the ROC assessment. So we’re looking at a low BMI. This measure is not looking at someone with
extremely high BMI. So for this particular risk, when it’s saying
someone who’s below. All right. So those give you a sense of the covariates,
the numerator and the denominator. Now we’re going to look a little bit, just
so that we can walk through and you’ve at least heard about how do we calculate the
quality measure and the algorithm. And to calculate the agency-observed score,
we look at calculating the denominator count. We calculate the total number of patients
with a selected target OASIS assessment in the measure time window who do not meet the
exclusionary criteria. So it’s everyone who fits in that timeframe
and then we pull out those that are excluded. And then what’s left is our denominator in
simple terms. That’s what that is. Two, we need to calculate the numerator count. And we calculate the total number of patients
in the denominator whose OASIS assessment indicates one or more new or worsened pressure
ulcers at discharge as compared to the start or resumption of care. And then the next one is, we calculate the
agency’s blank? Observed score. Very good. Okay. We divide the agency’s numerator count by
the denominator count, and we talked about that earlier, to obtain the agency’s observed
score. That is dividing the results of step two by
step one. All right. So we actually gave the example with the cookies. So that was helpful. So now we have the expected score for each
patient. We determine the presence or absence of a
pressure ulcer blank for each patient? Covariants for each patient. Exactly. We use the patient-level covariates and a
logistic regression. How many people know what a logistic regression
is? Usually there’s like one in the whole group. (Laughter) Okay. You don’t need to know this. It’s advanced math. I know what it is. I don’t do well with it. And I’m just finishing up my doctorate. So you know, that’s when you hire a really
good analyst and statistician and whatnot. But there is this whole process to do logistic
regression, just so we put it out there. You can talk about it over a cocktail party
that you can say those words. And you’re going to sound really smart. (Laughter) But we use that logistic regression
model to calculate a patient-level expected QM scores. So it’s basically a logic model. It says, if you have this, you know, these
conditions and this many patients, you should have X on the backend. And it’s a probability that the patient will
experience an ulcer given the presence or absence of risk characteristics measured by
the covariates. That’s the real simple terms. What are my chances of developing an ulcer
if I have peripheral vascular disease, and diabetes, and bowel incontinence and a variety
of different things, versus what are my risks if I’m up and and about, and have no incontinence
and I don’t have peripheral vascular disease? That’s kind of the simple term around that. And then step six, calculating the agency
expected score. Once an expected QM score has been calculated
for all the patients, calculate the mean agency-level blank QM score by averaging all patient-level
expected scores? So what are we saying that is? Expected, right. So we’ll get the expected score once we do
that. And then calculate the denominator count. Calculate the total number of patients retained
after exclusion and sum for the nation. Note that the sample will include only those
patients with non-missing data for the component of the covariates. So basically what that says, if you have missing
data in some of these items, they can’t make an assumption that they know what was going
on with that particular patient. So if the data isn’t there, by nature of it
being absent, they have to be excluded. That’s all that that’s saying to you. Then calculate the numerator count. Calculate the total number of patients that
triggered the QM and sum for the national measure. Then we go to step nine. We divide — to calculate the national mean
observed QM score, we divide the numerator count by its denominator count. Now, we’ve taken it outside of your agency
and we’re looking at it at a national level. And then you get the national observed score. This is dividing the results of step 8 by
the results of step 7. So it’s taking the same idea that you would
do at the agency level, but now we’re looking at a national level. So you have an expected score that you have
in your particular agency, now we’re looking at the mean score across the nation. Calculate the agency-level blank score? Right, adjusted score. And so, it sounds pretty complicated. But I think it’s important that you understand
that there are risk adjusters in these particular measures. They’re not just straight measures. And then those will be calculated at the agency
level, and then at the national level. All right. So now let’s get into the selected OASIS-C2
items, the 1311, the current number of unhealed pressure ulcers at each stage, and then M1313,
which has worsening in pressure ulcer status since the start of care or resumption of care,
or the SOC or the ROC. So just a little bit, we’re going to document
the number and stage and the status of pressure ulcers. And so we’re defining pressure ulcers as localized
injury to the skin or underlying tissue, usually over bony prominences as a result of pressure,
or pressure in combination with shear and friction. So that’s an important thing. So you need to make sure, what would be a
key component of a pressure ulcer? What one thing would you need to be able to
do if you were defining something as a pressure ulcer? Anyone have an ideas? I’m hearing a lot of different things. But do you think you would need to be able
to relieve pressure? Right. So there needs to be a pressure component
of it, whether it be from a device, or how they’re positioned in maybe a chair, or in
the bed, or whatever. So pressure needs to be involved with it. So this gets into — we’ll talk a little bit
about this when we go through it, is when you’re starting to look at pressure ulcers
in areas like on the leg. And We’re trying to decide is this a stasis
ulcer? Is it another type of ulcer? Or is it a pressure ulcer? Because you can have ulcers on legs if you
have like , you know, if you’re using an AFO or something like that. And all of a sudden it’s the splint that’s
causing pressure, okay. Where you would say normally, well gee, if
I’m having an ulcer on a mid-calf, normal it’s not over a bony prominence. You know what I mean? You’re saying, well is it pressure? Well if you put the splint on it, and the
splint lines up directly with that, they’re more likely than not maybe it’s a pressure
component to it. So pressure needs to be able to be relieved. So the overarching principles, staging definitions
are adapted from the 2007 National Pressure Ulcer Advisory Panel Clinical Practice Guidelines. The OASIS-C2 does not preclude home health
agencies from providing complete and ongoing skin assessment using accepted clinical practice
and guidelines in the clinical record. And identify and evaluate risk and determine
the etiology of each and all skin ulcers, wounds and lesions to ensure that you have
proper treatment. CMS is aware — and this has come up in the
other settings when we’ve done these cross-setting measures that there are new guidelines. There’s actually new terminology from pressure
ulcer to pressure injury. So currently, when you think about how complex
our system is within all of the various settings where we are gathering, collecting data, and
then publicly reporting it, I use the analogy of every time we need to change something
it’s not like, oh, well just change it like that. There’s huge implications to doing that. It’s like throwing a little pebble in a pond,
that ripple effect. So throwing the pebble is easy. It’s all the ripples that go out from that. So I know that CMS, this has been brought
forward to them. They are looking at this. But I just wanted to acknowledge it, that
it’s not like CMS is not aware that there have been updated guidelines since 2007. And there are these other things going on. The other thing to take into consideration,
and this is a caveat for me, Ann Spenard, who’s been working along with this for a long
time is that, I don’t know that we’ll ever be 100% current. You know, when we look at the evolving change
of healthcare, wound care, technologies and whatnot, every time we go to change anything
in these assessment forms and how we calculate and publicly report it takes time. So, you know, it’s not like we can make a
decision today and change it tomorrow. So that if a new guideline came out tomorrow,
could it be changed within a month? No. So will we always kind of be little bit behind? I think so. I think the caveat that is in this slide says,
it doesn’t preclude you in your organization, if you want to start calling things pressure
injuries, that’s okay. Call them pressure injuries. Use the current standard guidelines and practices
in your clinical practice. And then just use the guidelines that are
provided in your manual on how to code the OASIS tool. So hopefully that is helpful to you. So M1311 current number of unhealed pressure
ulcers at each stage. So what we’re looking at here is the OASIS-C1
item as compared to the C-2 item. So we looked at C1. It says the current number of unhealed pressure
ulcers at each stage are unstageable. And then the new item, which is now coded
a different number. So if you had these committed to memory, as
many people have, it goes from 1308 to M1311. And it’s the current number of unhealed pressure
ulcers at each stage. So there’s — it’s going to take a little
bit of time maybe for your staff thinking about the numbers and whatnot. So you want to make sure that everyone understands
that it’s not a dramatic change, but there are some changes. What I wanted to show you here in the next
two slides is, this is the current way when you go into your assessment form how it is
presented. And then when you look at the OASIS-C2, and
this is not meant for you to read because it’s teeny tiny up there. But this is what you’re going to see if you
were looking at a screenshot of the tool. And we’re going to go through item by item
so that you’ll be able to clearly see this. So it’s important again for staff to understand
that it’s going to look different. So think about that from your action items. How are you going to educate your staff, just
to make sure they understand the changes in the numbering, and how it’s going to look
so that staff do not get distressed over this process. So M1311 item intent, it identifies the number
of stage 2 or higher pressure ulcers at each stage present at the time of the assessment. And stage 1 pressure ulcers and pressure ulcers
that have healed are not reported in this item. So if you have a stage 1, that doesn’t mean
you shouldn’t clinically address it, okay. Okay. Please remember that. It’s just saying you’re not going to report
it off on this. And certainly if you have a healed pressure
ulcer, again, you’re not going to report it here. But I would hope that you’re going to engage
with that in your care plan, right, and what you’re going to do to help prevent and make
sure that that particular item or area doesn’t open again. Because it’s at higher risk. So the time points to complete this are at
the Start of Care, your SOC, your Resumption of Care, your ROC, your follow-up day, or
follow-up which is your 60-day assessments, and then discharge from agency, not inpatient
and not discharged to the inpatient or death. And when we look at the timeframes for completing
this when the assessments — so we’re going to take a little bit about this in some of
our scenarios. Just remember your timeframes when you’re
trying to encode these particular items. So at your start of care, the assessments
should be completed within five days after the start of care. And then your ROC of course is two days. Your follow-up you have within that 5-day
window. And then discharge from agency within two
days. I’m not telling you anything you don’t already
know. But I just wanted to remind you of that. Okay. So let’s talk a little bit about actually
going in and starting to code these. So terminology referring to “healed” vs. “unhealed”
ulcers refers to whether the ulcer is closed versus opened. So who here has dealt with pressure ulcers
from a clinical perspective? A few of you. So I want to just spend a second on explaining
this for you that maybe are not so clinical oriented, or haven’t done this in a long time. So when we say it’s healed versus unhealed
we’re saying whether it’s closed. So meaning that the skin has completely closed. But what can happen, and any of you who have
dealt with pressure ulcers is sometimes the skin closes, but the wound underneath hasn’t
— the tissue underneath hasn’t healed. So the skin piece, the epithelialization has
happened, but actually we haven’t had wound healing from the bed up. And then of course for those of you who have
gone into a little bit more detail around wounds, you know that even when it’s completely
healed and whatnot, the tensile strength, the actual strength of that skin and the structure
below it is at its maximum, 80% of what it was before it ever became a pressure ulcer. So it’s never as good as the skin we were
born with, okay, the original skin that we had. So you could say something closed, and then
it can open up if we don’t pay attention. And, you know, it can open up and be kind
of that gaping wound underneath. So we have seen that. So stage 1 pressure ulcers and suspected deep
tissue injuries, although they’re closed, okay — so if you have a stage 1, and we know
that that’s kind of a persistent red area, non-blanching, or suspected deep tissue injury,
meaning it’s usually that purpley dark color to it, although it’s closed — so the skin’s
not open. It wouldn’t be considered healed. We don’t know what it is going to be, especially
if it’s suspected deep tissue injury. We don’t know when it decides to declare itself
what is it going to look like? Even though the tissue is closed, it’s not
considered healed. And then unstable pressure ulcers whether
covered with non-removable dressing, eschar or slough would not be considered a healed
ulcer either. These are subtleties but important to make
sure that your staff understand as they go out and they complete the OASIS, especially
in home care. Because you may have many, many nurses completing
the OASIS. Is that correct? Right, okay. As compared to an inpatient rehab facility,
a long-term care hospital or skilled nursing facility where you have far fewer people who
are actually encoding the assessments. So you have this tremendous workforce. You’ve got to train a whole lot of people
and make sure that they understand how to accurately assess and then code the OASIS
as compared to probably a much smaller number in some of the other settings. So I think your job is a little harder and
far-reaching, but just as important to make sure that they understand all of these subtleties. Then we want to look at present on admission
equals for you in home health means, at the start of care or resumption of care for each
pressure ulcer. Determine whether the pressure ulcer was present
at the time of the most recent start of care resumption of care, and did not develop during
the home health quality episode. So this is really important to get out to
staff and to know exactly what your patient looks like when you take them onto service. Patient assessments are completed as close
to the actual time of the start of care resumption of care as possible. And if a pressure ulcer that is identified
on the start of care date increases in numerical stage or worsens within the assessment timeframe,
the initial stage of the pressure ulcer would be reported in M1311 at the start of care. So let me explain some of these bullet points
here . So again this is a cross-setting measure. So these questions actually came up in some
of the other healthcare settings. So If I’m in a institution, I’m in a building,
right. I’m in a skilled nursing, I’m in a inpatient
rehab facility or long-term care hospital, we have nursing 24-hours a day. I may have done your skin assessment in the
first eight hours of you being in the walls of my particular facility. So let’s say I assessed you as having a stage
2 on your coccyx. Now, three days later, I go in and I’m still
within my 5-day assessment period. But now your stage 2 has gone to a stage 3
because it’s, you know, partially covered in slough. So what do I do to code? Well that’s where this caveat came in. You have to do it the closest to when they
came into your organization. So think about your setting. Think about home health. So if your RN is going out to do your assessment
and they go out within 24-hours of discharge from let’s say the acute setting, and you
do an assessment and for some reason you’re back out there two days later or three days
later, so you’re within that 5-day window, if something has changed in that wound, what
we’re saying here is please encode what you found on your first visit. That’s what this is saying to you. The writing around this is really — you know,
trying to cover, straddle two kind of environments, the structured kind of four walls environment,
and then home care, which has it’s own challenges. For the SOC or ROC, you want to enter response
for Rows A1-F1. You want to enter the number of pressure ulcers
that were currently present. And if you don’t have any pressure ulcers
on that particular stage, just go ahead and please enter a 0. In this, at follow-up or discharge enter the
responses. And what you’ll see is we have A1 and A2,
B1 and B2. And we’re going to go through these in more
detail. So A1-F1 is enter the number of pressure ulcers
that are currently present so. We’re looking at, let’s say it’s a follow-up
at 60 days later. What do I see now? And enter 0 if there’s no pressure ulcers. And then A2-F2 enter the number of pressure
ulcers that were present on admission. So it will say, of these ulcers, how many
of these were present when I did my start of care or my resumption of care. And we’re go to go through these in detail. But that’s what we’re looking at for those
assessments. So we have the stage 2 pressure ulcers. And this goes through it. It defines it as a partial thickness loss
of dermis presenting as a shallow open ulcer with red-pink wound bed without slough, and
also may be present as an intact or ruptured blister. These haven’t changed for you. Those have been there. And so, the important thing is, and I’m going
to go through this in each one of these as we go through from a stage 2, 3, 4, and 5
is, are you confident as you sit here today that all of your nurses that are completing
the OASIS are competent in assessing skin? You don’t need to raise your hands. (Laughter) Do a little soul searching. Think about it. Is this an opportunity for some improvement? Because this matters, okay. So this is going into the quality reporting
system. So if I say that I have a nurse who goes out
and encodes and says the person has a stage 2 pressure ulcer on their coccyx. And then they describe in a narrative-type
note that the wound has some slough, not completely occluding it, but that ulcer has some slough
in it. Can that be a stage 2? No. Are you confident that all your staff know
that? No. (Laughter) Good, you’re being honest. Because guess what, that’s probably the biggest
caveat or the hardest areas is from those, from between stage 2s and stage 3s. So you want to make — unless they’re a obvious
stage 3, much deeper and whatnot. But you can’t have slough in a stage 2. So take the opportunity to make sure that
your staff truly understand. And you can use some scenarios that we’re
going to go through here and think about some of the other education that you can do in
your particular facilities to make sure that your staff really understand what they’re
looking at, and what they are actually capturing. So if you’re doing some quality audits, does
anyone do quality audits of their records? Of course you do, right. (Laughter) So are you looking at that detail
though? Are you looking at what’s coded on the OASIS
versus what’s documented maybe in the clinical record? And if there’s an opportunity — where you
really see it usually is in a clinical note somewhere, where they’re describing what they’re
seeing. That’s where you might find a great opportunity
to do some education. And if it’s just a couple of staff members,
go ahead and educate just a few staff members. But if it’s a system-wide hit or miss, take
the opportunity to determine some of the competencies within your staff around these particular
areas. All right. I’ve done preaching for that. (Laughter) And I’ve preached to every group. Because I’ve taught this in each one of the
settings. So I’ve preached to all of the groups on this. They’ve all heard the same messaging. So Stage 3 talks about full thickness tissue
loss and subcutaneous fat. Fat may be visible but not bone and tendon. Slough maybe present but does not obscure
the depth of the tissue. So, you know, you can see to it’s deepest
point. And then you can go ahead and code this as
a stage 3. And we just talked about that. And then stage 4, those are the most unfortunate. But it’s full thickness, tissue loss with
exposed bone, tendon and muscle. And just remember that in this particular
— it could include undermining and tunneling. And actually stage 3 could have some undermining
or tunneling. If any bone, tendon, muscle or joint capsule
is visual, the pressure ulcer should be reported as a stage 4 pressure ulcer, regardless of
the presence or absence of slough and or eschar. So you could have a little bit of eschar,
a little bit of slough, but if you see bone, it’s a 4. No question about it. If you see bone, okay, bone or tendon. Think about this, and this is where staff
struggle a little bit too. Think about the outer malleolus, you know
the ankle. Like there’s not a lot there, right. It’s different than if you get to a hip, you
know, and stuff where you have maybe a little bit more padding to get through. So you can get to a stage 4 pretty quickly
in those particular areas versus maybe in the sacral area. So again, making sure that we have staff that
understand how to code it. So let’s go into a little bit about the unstageables. So unstageable non-removable dressing or device. And what we’re looking at here is that you
know that there’s something there, but it’s not stageable due to you can’t remove the
dressing. And something might be that they have a cast. They could have some sort of a primary surgical
dressing that you don’t have orders to remove. So you can’t — you want to peek under it,
but you can’t and take a look. So you know something’s going on there. But you yourself can’t put eyes on it to determine
what it is. So we’re saying that you have something there. But it’s unstageable due to the fact that
you can’t remove the dressing. At a later date hopefully the dressing will
be removed, the cast will be removed. Whatever it is that’s obscuring your ability
to take a look at it will be removed, and then you can actually code whatever stage
that you find it at. So they can be a primary — I talked about
this, primary surgical dressing, orthopedic device, a cast or whatnot. And it’s just that you have an order their
you can’t remove that. So let’s talk about slough and eschar. And I think this is an item that you were
always answering. But unstageable because the wound bed is covered
and you can’t see to it’s deepest anatomical point to be able to clearly be able to determine
what stage the pressure ulcer is. And here we’re looking at — so the true anatomical
depth of the soft tissue you can’t see it, you can’t determine it. The pressure ulcer stage can be determined
only when enough of the slough is removed. So if I had something that was completely
covered with slough or eschar, and then it got chemically or surgically debrided then
all of a sudden I see bone, well then can I code it at that point as a stage 4. But prior to that point I can’t say. I don’t really know what’s underneath. And just to go through and to make sure everyone
understands what we’re talking about, so, slough is non-viable, yellow, tan, green,
gray, brown tissue. It’s stringy, it’s sticky, it’s yucky. It doesn’t easily clean off. And it’s adherent to the base of the wound
and present in clumps throughout the wound bed. These are wonderful things to talk about before
lunch. I just thought I would tell you that. You’re lucky that I’m not showing pictures. I use to do things like that. People are like Ahhh! We actually talked about that. Should we add pictures during this training? We’re like, not everyone’s a nurse. The nurses would be like oh, it’s cool. I like that. It’s neat! Everyone else would be going, ugh, I’m nauseous. It’s interesting in our offices, we’ve done
a lot of trainings. We have support staff, they’re like, do I
have to do that? Do I really have to look at those pictures? (Laughter) Anyway, so eschar is dead or devitalized
tissue. It can be hard or soft in texture. It’s usually that black, brown or tan in color. But it’s more like a scab. I think that’s a good example to use for eschar. It’s really stuck on. It’s necrotic tissue. It’s usually firmly adhered to the base of
the wound and off to the sides or the edges of the wound. Both are used to say, I don’t know what’s
underneath. I may suspect that I know what’s underneath. But until you surgically or chemically debride
that and get rid of it, I have no idea whether I’m dealing with stage 3 or stage 4. We know it can’t be a stage 2, right. We know at least it’s a 3. But we don’t know if it’s a 4. So just remember that. And then we have this unstageable suspected
deep tissue injury. And we talked a little bit about this earlier. And suspected deep tissue injury are a purple
or maroon area of discolored intact skin due to damage of underlying issue. And a very common place that we see suspected
deep tissues is the heels. Yes. Very common in the heels. The area may be preceded by tissue that’s
painful. It may be firm or mushy. It could be boggy or warm. It could be cooler. Really what you’re saying is, there’s something
going on with the tissue surrounding that particular area. Now the other thing to remember is that deep
tissue injuries maybe difficult to detect in individuals with darker skin tones. So when you think about someone who has very
dark skin tones, a suspected deep tissue would be much harder to pick up on them than say
myself who I’m very pale. So you would pick up purpling, dark color
on my very easy. With someone who has a lot of melanin, or
dark skin, it can be really hard. So you’ve got to look. And you have to look. And you have to look with really good light
in the areas that you might suspect that you would see some of these injuries. And you might — it really — that purpley
hues and stuff could be really hard to pick up. So make sure that again your staff are educated
in doing that. A evolution can include a blister over dark
wound bed. The wound may further evolve and become covered
with a thin layer of eschar. And evolution maybe rapid, exposing additional
layers of tissue even with optimal treatment. So the thing about a suspected deep tissue
injury is, until — I call it “declaring itself” until it tells us what it really is, so we
see a purple area, we don’t know if that’s superficial damage or how deep that damage
is. Think of it almost like the tip of an iceberg. And until it opens up and tells us what it
is, you know, I’ve seen areas, especially in the heel where that purple area just really
just continues to stay purple. And It ultimately re-absorbes and goes away. And I’ve seen those heels go to eschar, okay,
that thick leathery brown. Then you do everything you need to do, and
over time, it’s like a scab. Little pieces fall away. And by the time the eschar is gone you see
this healed skin underneath. And I’ve had others that have opened up and
you’re right to the bone. So you really don’t know what you’re going
to get as these evolve. But they are important. And we need to pay attention to them. Okay. So what are some of the data sources or resources
that we can use when we’re trying to understand someone’s skin condition, patient or caregiver
interviews? And those would be important for you to know
about. History, if someone had a history of pressure
ulcers. Oh, gee, my mom had a really bad hip pressure
ulcer. It was two years ago and it’s healed. But that skin’s never been the same. And that family member’s right. That skin will never be the same. But that’s important for you to know when
you going to care for that person. You’re going to keep a close eye on that. Certainly your observations are critically
important. What does your physical assessment show? So are you doing a good assessment? What is your clinical record telling you? So what’s your transfer documents, whatever
information that you’re getting from the previous care setting including your referral documents. What’s your physician telling you? Hopefully your physician has seen the patient. (Laughter) And know what’s going on. So your primary care may not have been the
person who saw the patient. It may have been your hospitalist or could
have been your SNF or SNFist, whatever they’re calling them now or from the previous setting. What kind of documentation are they sending
along? Then there’s additional resources in Chapter
5 of the OASIS Guideline Manual, which will help guide you in this. But think about in your own agency, where
would your staff find some of the documentation? Short of them going out, which they need to
do anyway in their own eyes, and what they are assessing. What other documentation? Where else are they going to find the information
in your record or transfer documents? And then do they have access to those? Can they look at those and then validate what
they’re seeing when they go out to your patient? All right. M1311, so let’s look at this. A previously closed stage 3 or 4 pressure
ulcer that is currently open again. She should be reported at it’s worst stage. So think about that. Do we reverse stage? No. We did in skilled nursing for a lot of years. And so we had to change that practice. Actually the MDS required at one point that
we had to reverse stage. But of course, a stage 4 is always a stage
4, right. So if it was a stage 4, think about that earlier
example that I gave you where the skin closed over on it. Then it opened up again. Okay. Even if it was a stage 4 and you knew it was
to the bone, now it opens up and it looks like a stage 3. Okay. So it’s not quite down to the bone. Once that re-opens, that exact same area is
a stage 4. So are you confident that your staff would
code that that way? That’s a good one, right. Would they code it as a stage 3, what they’re
seeing? So think about that. How is that going to work in your particular
agency? If the patient had been in an inpatient setting
for some time, it’s conceivable that the wound has already started to granulate, thus making
it a challenge to know the stage of the wound at its worst. The clinician should make every effort to
contact the previous providers to determine And the ulcer can worsen and this item should
be answered using the worst stage if this occurs So it’s really important that if someone’s
coming to you with a stage 3 ulcer that you can verify that it was never worse than a
stage 3. Because if they’ve been from an acute-care
setting to say a skilled nursing or inpatient rehab facility, or a long-term care hospital
where they’re going to have longer lengths of stay, now they’re coming out to you and
you’re doing home care. That wound can be very different than what
the clinician is seeing from what it’s original stage was. So think about that. How do we ensure that we understand you in
the home care agency and your nurses understand what the worst stage of that ulcer was? »» So we looked at — there was a variety
of questions that came in during my session for the last hour before lunch. What I’d like to do, I’m going to address
some of these. But what I’d like to do is finish if I could
the presentation. I think some of the questions are going to
get answered as I go along. But then I will recap with the questions that
we have and the answers to make sure that you have the information that you need to
move forward. Okay. So we’re going to pick up from where we left
off. Let me just go to the next slide here. A couple of key things. And these are just tips around M1311. If someone has a muscle flap, a skin advanced
flap, rotation flap or anyone of those things to surgically replace the pressure ulcer,
the pressure ulcer moves from being a pressure ulcer to a surgical wound. And it would not be reported as a pressure
ulcer after that procedure in 1311. Okay. So you could have had the pressure ulcer. Now have the surgical flap, and now it becomes
a surgical wound. And then a pressure ulcer treated with a skin
graft should not be reported as a pressure ulcer until the graft edges completely heal. It should be reported as a surgical wound
in M1340. And then a pressure ulcer that has been surgically
debrided remains a pressure ulcer and should not be reported as a surgical wound. So we have two kinds of examples where something
was a pressure ulcer, had these procedures, now is considered a surgical wound. But if we are just doing a surgical debridement
of that pressure ulcer without doing a flap or anything else, it still remains a pressure
ulcer and should not be coded as a surgical wound. All right. So we’re going to actually go through and
do some practice scenarios. And I think is where we start to apply, and
I think this is where we’re going to start to apply and answer the questions that have
already come up both from the room and online. So hopefully you’ll find this helpful. So we have a practice scenario here. And so we’ll look at the scenario together. So at the start of care the patient has three
small stage 2 pressure ulcers on her sacral area. Actually, I think there is a form in the Downloads
section. And you should have it in your folder for
coding scenarios. It’s just basically we took the item portions
of the item set, I think it’s on your right-hand side if you’re in the room here. So you’ll see Section M — can everyone find
it? I’m sorry I don’t have a copy of it. Do you have it there so I can — so I don’t
know those watching on livestreaming if you can see this but it’s Home Health Quality
Reporting Program M1311 and 1313 Practice Scenario Sheets. That’s the title of it. Looks like this, has lots of little boxes
on it. If you can pull that out it will be very helpful
as we go through some of these practice scenarios. Has everyone found it? Hopefully those of you who are on livestream
can go pull this out also. It is stapled. So it has multiple pages to it. It’s in your folder. It definitely there. I’m looking around the room. I think some people are struggling. Has everyone got it? Okay, great. All right. Good. So just keep that handy and use this with
this coding scenario. So here we have a — at the start of care
you assess the patient and they have three small stage 2 pressure ulcers, and this patient
happens to be female on her sacral area. Upon discharge, the sacrum is assessed and
two of the stage 2 pressure ulcers have merged. And the third ulcer has increased to a stage
3. So we have a practice scenario. So we’re going to go through this. But if you can take out your coding sheet
and let’s code these items. I’m going to give you just a second to code
it. And Then we’re going to go through the answers. So this is what you’re going to be looking
at. This is what you should have on your paper. For those of you livestreaming and you haven’t
pulled this down, you might get frustrated, just take a scrap piece of paper, and just
code these along with us. All right. Everyone have written down your answers? All right. So let’s look at this M1311A1, the number
of stage 2 pressure ulcers. And this is the start of care resumption of
care. What are we going to code there? How many ulcers? 3, very good. Okay. So we look at that. We have stage 3. Then we’re looking at the number of stage
2 pressure ulcers at discharge. How many do we have? I hear 1. Does everyone agree with that? I hear some 3. But how many — so this is discharge. So on the start of care or resumption of care
we started off with three stage 2 pressure ulcers. And now we’re at discharge. How many do we have? 1. Good. So we have 1. All right. So we have one stage 2. And the reason for that is that we had three
stage 2s to start with. But two of them merged together. So when they merge together they haven’t increased
in depth, okay. But those two became one. Sometimes you’ll have that, that small little
band of skin that separates them. Now that skin is gone. It’s not increased in its staging, but now
those two stage 2 ulcers have become one stage 2 ulcer. Okay. That’s where that scenario comes from. All right. The next question is, M1311A2. So the question is asking the number of these
stage 2 pressure ulcers that were present at the most recent SOC/ROC. So think. Read the question carefully. The number of these stage 2s, when they’re
talking about stage 2s, they mean the ones that you just talked about. Okay, the previous question. So the number of these stage 2 pressure ulcers
that were present on the most recent SOC/ROC? So I hear a 3. What else do I hear? 1. Okay. So let’s talk about it. The answer is 1. Now let me explain to you why. Because this is important. So what we’re looking at here is 1311A2 says,
because of these ulcers, so we said there was one stage 2 okay at discharge. Then it’s saying to you, of those, how many
were present at the start of care or resumption of care? Okay. So it’s looking at the question before it,
right above it. Of the one also that I had, how many of those
were present at the SOC/ROC? And it’s saying 1. It could be 0, right. It could be that it developed. All right. So it’s saying I have one at discharge but
it wasn’t there at the start of care. So that answer could be either. But that’s — so it’s a subtly there. But that’s what we’re looking for in that
particular question. All right. Oh, I gave you the answer, okay. So the number of stage 3 pressure ulcers,
so that’s 1311B1. The number of stage 3 pressure ulcers at the
start of care? 0. Right. They didn’t have any, right. They didn’t have any. They came in with three stage 2s. Now the next question, remember that’s a follow-up
question. So it’s saying, the number of these stage
3 pressure ulcers that were present on the most recent SOC/ROC? I’m sorry. I’m sorry — I went down the next row. I’m sorry. So let me go back. So we started off with the number of stage
3 pressure ulcers. And we’re looking at the SOC/ROC and that
was 0. Then we go across to the right. And this is the discharge assessment. So we had the start of care assessment and
now we have the discharge assessment. The discharge assessment says the number of
stage 3 pressure ulcers that we had? 1. Right. My error in doing that. I was jumping ahead. Then the next question says, now we’re looking
at the discharge assessments. So we’re looking, we have one stage 3. The number of these stage 3 pressure ulcers
that were present on the most recent SOC/ROC? 0. Right. Right. Because they didn’t have any, all right. So think about these. The first column there was looking at the
start of care resumption of care. And then as compared to, we’re comparing the
two assessments at the discharge. All right. We’re going to have more opportunities to
practice. All right. So then the rationale behind this, two of
the pressure ulcers on the sacrum have merged. But have remained at the same stage — remained
at the same stage as they were start of care so M1311A 1 is coded as 1 at discharge. The pressure ulcer that increased in numerical
stage at stage 3 has developed a deeper level okay. So it’s advanced. It’s tissue damaged since the start of care. Therefore on the discharge assessment, M1311B2
is coded as 0 not present on the start of care or the ROC. That’s the rationale behind that. I would encourage you as we go through these,
you can take these back to your own organization you use these or you can use your own patients
and you can do similar types of education for your nurses to make sure that they’ve
got the subtleties around this. All right. If you take your form that we were doing the
practice scenario sheets and you go to your — flip it over and go to your next scenario. So now we’re looking at Scenario 2. So at the start of care Ms. J’s admitted with
four stage 2 pressure ulcers and one stage 3 pressure ulcer. During Mrs. Jones’s home health quality episode
three of the stage 2 pressure ulcers healed. However Mrs. J developed an additional stage
3 pressure ulcer. So a slightly different version. And if you look at your form here, your practice
scenario form it’s got the key elements already that we just talked about. I’d like you to just take a second and code
your form. For those of you at home, not at home but
on the streaming video, again you can just write these on a scrap piece of paper if you
haven’t pulled down the practice scenarios. Just give it a moment. People are diligently answering. Okay. So for the first question, 1311A1 number of
stage 2 pressure ulcers on the start of care the SOC/ROC? 4. Correct. Okay. The next question is the number of stage 2
pressure ulcers at discharge? 0, 1, 2? What are we hearing? 2, okay. So it actually 1. Okay. So let’s talk about that. At the start of care, Mrs. Jones was admitted
with four stage 2 pressure ulcers. So that’s how we got our first answer and
one stage 3 pressure ulcer. During her home health quality episode three
of the stage 2 pressure ulcers healed. So she had four, we take away three and it
leaves us what? We wrote this in a little bit of a confusing
way, right. So you need to peel back the onion and make
sure you’re understanding the pieces okay so there was one stage 2 left. All right. So the next question says, the number of these
stage 2 pressure ulcers that were present on the most recent SOC/ROC? Right. And we just kind of explained that right. Okay. Exactly. Code 1. The number of stage 3 pressure ulcers at the
SOC/ROC? I hear 0 and 1. What do we think? 1. Majority says 1 and that is correct. But why is that correct? Well, we said she had four stage 2 pressure
ulcers and one stage 3 upon admission, right. Okay. So that’s how we get the answer there. So on admission in the SOC/ROC she had one. All right. So the next question says, number of stage
3 pressure ulcers at discharge? 2, okay. You guys are good okay. They had the original one on discharge, right,
that they had when they started care. And then they developed an additional one. All right. So now we had 2. Very good. The number of these stage 3 pressure ulcers
that were present at the most recent start of care or SOC/ROC? 1. You got it. Okay. You code it as 1. Very good. And so there are four stage 2 pressure ulcers
on the SOC but prior to discharge three of the four stage 2s healed that left us one. Then they had one stage 3 upon admission. They continued with that one stage 3 and then
they had an additional stage 3 ulcer that developed. And that’s how we came up with our coding. Getting it now? Okay, great so. We have now — I’m sorry? (Low Audio) Okay. So we’re having some questions. So 1311B2 you have a question on? Okay. So let’s spend a second on 1311B2. So what it’s saying is, the number of these
stage 3 pressure ulcers — so we’re saying we have — this is the discharge assessment. We’re saying now we have 2 stage 3 pressure
ulcers, right. Then the follow-up question is saying, okay
so you have two. How many of those pressure ulcers, those stage
3 pressure ulcers were on the SOC/ROC? 1. So that leaves us one left. Right, one that wasn’t there when we started. Do you see how follow-up questions are referring
to the previous coding? Does that answer the question to the room? Yes? Okay. Clarifies it? Great. All right. We talked about the rationale. All right. So we have practice Scenario 3. So if you go to your practice Scenario 3 on
your handouts that would be great. So in this scenario at the start of care Ms.
P was admitted with a diagnosis of a stroke with a right hemiparesis and assessed to have
a 1cm X 1cm X 0.1mm stage 2 pressure ulcer on her coccyx. Ms. P continued to decline at home with decreased
appetite, frequent TIA’s and a wish not to be hospitalized again. After palliative care consult, the patient
and family agreed to hospice care. Upon discharge from home care Ms. P was noted
to have a pressure ulcer covered with eschar on her left heel and a stage 3 pressure ulcer
3cm X 2cm X 0.4 mm on her coccyx. So I’m going to give you a second. This one’s a little bit more involved. And we’re going to do this practice scenario. So I’m going to give you a moment because
there’s lots of question to answer. Remember all the information, if you’re following
along on the sheet, all the details are on the different types of ulcers is on the top
of the scenario case. Okay. How’s everyone doing? Just giving another moment. People are still diligently writing. Just giving another moment. So you see how much time it’s taking to think
through this? So make sure your nurses can do the same thing. This would be a good scenario to use in training. Okay. Trying to stick to schedule. We’ve got a lot more to cover. Let’s go through the scenario. Okay. So let’s look at the first item, the number
of stage 2 pressure ulcers present upon start of care? 1. Okay, great 1. So now let’s look at the next thing, the number
of stage 2 pressure ulcers present at discharge? 0. They didn’t have any at discharge. Now, so the next question and we haven’t talked
about this before, so the next question says the number of these stage 2 pressure ulcers
that were present at most recent SOC/ROC? What would you do here? Actually it’s skip pattern. It was a trick. (Laughter) So think about this. If you’re doing this in an automated system
it would skip you down to the next question. Because it’s asking of these, and you’re say
you have 0. So you can’t say of 0 what you had present. So really this would be a skip pattern. So we’re showing it here. It would be probably seamless for you in electronic
health record. It would just progress you to the next question. The number of stage 3 pressure ulcers upon
admission start of care or resumption of care? Okay great, 0. And then how about at discharge? We’re looking at stage 3? 1, very good. You guys are good. Number of these stage 3 pressure ulcers that
were present upon the most recent SOC/ROC? Right, 0. All right. The next question is number of stage 4 pressure
ulcers SOC/ROC? 0. Okay. And how many of them at discharge? 0. Correct. Okay. So then the number of the stage 4 pressure
ulcers that were present on the most recent SOC/ROC? Skip. Remember that’s a skip pattern. Because we had 0 we’re going to skip through. We don’t have any to look at. So now we’re starting to get into some of
the unstageable questions. Sothe number of unstageable pressure ulcers
for non-removable dressing for start of care? 0. We didn’t have any. And this is because of non-removable dressing,
specifically non-removable dressing. Okay, so casts, things like that. All right. And then how about at discharge? 0. Right. So they didn’t have — and this is specifically
related to non-removable dressing. All right. So then the next question says, number of
these pressure ulcers that were — let’s see, the number of these unstageable pressure ulcers
that were present at most recent SOC/ROC? Skip. Skip, skip, skip. Okay. Then we’re looking at the number of unstageable
pressure ulcers for slough and eschar on the start of care? 0. Right. Then how about at discharge? 1. Correct. Number of those unstageable pressure ulcers
due to slough and eschar that were present on the SOC/ROC? 0. Right. Okay it wasn’t there when you started. And then number of unstageable pressure ulcers
suspected deep tissue injuries on SOC/ROC? 0. Right. How about at discharge? 0 is correct. So this is specifically looking at suspected
deep tissue. Suspected deep tissues. So there’s three different ones that you’re
looking at, okay. Unstageable due to non-removable dressing,
unstageable due to eschar or slough, unstageable due to suspected deep tissue. Those are three separate questions that you’re
asking. All right. And the number of these unstageable pressure
ulcers that were present on the most present SOC/ROC? Right. We actually have a 0 here, that’s wrong. It should be a skip. Very good. So we went through a lot — that’s kind of
a detailed one. It’s probably a good training scenario to
use with your staff. So in the rationale it’s a stage 2 pressure
ulcer on the coccyx was present on start of care but deteriorated to a stage 3. Then Ms. P also develop add new heel pressure
ulcer during her home health quality episode that was unstageable upon discharge due to
eschar. So that just gives you a sense about answering
some of those questions. So M1313, worsening in pressure ulcers since
the SOC/ROC. And what we look here in the OASISC-1 items
1309 had worsening in pressure ulcer status since SOC/ROC. And 1313 is worsening in pressure ulcer status
in SOC/ROC. So you’ll notice it went from 1309 to 1313
and expanded. So what we have here are the screenshots from
the OASIS-C1. So I think to note here is that you only were
coding unstageable due to the wound being covered by slough or eschar in C-1. And this is changing on OASIS-C2 to this is
your item set. So what we’ve highlighted there in the yellow
are the two additional areas that we’re looking at unstageable. So the two new ones are unstageable due to
non-removable dressing. And then you already have been doing unstageable
due to eschars and slough. And then we have F, which is new, which is
unstageable due to suspected deep tissue injury. So when you go back to your organizations
or you’re starting to think about implementation and getting people up to date with all the
new guidelines, you want to make sure that you focus on the new items. But take the opportunity to validate that
everyone was doing it right any way. If you’re going to bring them in for education
or you’re going to do some education make sure they understand kind of all the things
that we’ve talked about today. The item intent is to document the number
of pressure ulcers present at discharge that were not present. Another way to think about that is new. So if it wasn’t present it’s new or worsened
meaning it’s increased in numerical stage since the most recent start or resumption
of care. Okay. If a pressure ulcer increases in numerical
stage from the SOC/ROC at discharge, it is considered worsened and would be included
in the count of worsened pressure ulcers at M1313 at discharge. And we’re going to go through some examples
on that. The time points for completion discharge within
two calendar days of the date of discharge, transfer or death. So let’s go through steps for assessment. You want to review the history of each pressure
ulcer. Compare the current stage at discharge to
past stage to determine whether any pressure ulcer currently present is new or at increased
numerical stage when compared to the most recent SOC/ROC. Remember we don’t reverse stage, okay. So if something gets worse that’s fine. But if it’s a stage 3, it’s a stage 3 until
it’s closed. Then for each current stage count the number
of current pressure ulcers that are new or have increased in numerical stage since the
last SOC/ROC that was completed. Okay. For pressure ulcers that are currently stage
2, 3, or 4, rows A, B and C mark a response for each row of this item. If at discharge there are currently no ulcers
at a given stage, you want to enter 0 for that stage or row. So if it’s asking you for stage 2 and they
don’t have any stage 2, you’re going to put a 0 in there. Report the number of current pressure ulcers
at each stage that are new or have worsened since the most recent SOC/ROC. So we’re going to go through here. So this is some scenarios. And what we’re looking at here is reporting
algorithm for M1313. So a stage 2 at discharge, if the same pressure
ulcer at most recent SOC/ROC was? Not present, if it was a stage 1. If it was covered with a non-removable dressing
device then document it as a stage 1 or at a higher home visit or follow-up assessment
then you report it as new or worsening. So let me give you some caveats around this. So if an ulcer on the start of care is covered
with eschar, not removable dressing or suspected deep tissue injury, when it first — you know
identifies itself, so now we’re able to remove the — let’s say the device and you say, oh,
okay, it’s a stage 2. We’re going to record this now as a stage
2, yes. And then when you go through the rest of these,
the stage 2, the answer would be no on the next one. Stage 3 or 4 it’s not applicable. We don’t have any. And then covered with a non-removable dressing? Well we’d say no, because that non-removable
dressing component is gone. And then if you go through these it takes
you through these algorithms, take you through each one the same thing. If it was — if the staging, we’re looking
at a stage 3 at discharge, if it wasn’t present, if it was a stage 1 or 2 or it was unstageable
and now you can stage it, we’re going to code it as a yes. Okay. And then stage 3 would be no. Stage 4 would be NA. And then unstageable until assessed at a stage
3 at discharge, no. So there’s an algorithm for each one of these. We’re going to go through. Stage 4 and then the unstageable. So again these are looking at the discharge
assessments. Here’s one for non-removable dressing. So it’s unstageable due to non-removable dressing. If the same pressure ulcer at most recent
to SOC/ROC was not present then we answer yes here. And we do the same thing for slough and eschar
and the same thing for deep tissue. So let me just go — and we’re going to go
through some practice scenarios. I think that’s the easiest way to gather this
data. So let’s talk about the use of the dash at
1313. A dash value is a valid response for these
items. A dash value indicates no information is available
or an item could not be assessed. This most often occurs when the patient is
unexpectedly transferred, is discharged or dies before assessment of the item could be
completed. So you know, suddenly they die or you haven’t
had the opportunity to do this. You can put a dash. And CMS expects the dash to be used in a rare
occasion. So more likely than not on almost all of these
assessments you will be able to code. But if for some reason you didn’t have the
data, you couldn’t — and they could not be assessed. And I’m not saying couldn’t be assessed because
it was covered with a dressing, a non-removable dressing. But here you just didn’t have the opportunity
to assess it, you’d have to put a dash. And I think a dash is new for home health? Yeah. Okay. You use the dash — let me just caution you. You use the dash very judiciously. But it is a valid response. But it’s only used — you’ve exhausted all
efforts to be able to get the information. And then you would use a dash. Some of these tips we’ve already talked about. Don’t reverse stage pressure ulcers as a way
to document healing as it does not accurately characterize what’s occurring physiology in
the pressure ulcer. Some of the questions and discussions we’ve
had during the break, well, wait a minute, what happens? I’m assessing it. It looks like a stage 2 or a 3. But it was 4 from the previous setting. It’s a 4 until it’s closed, right. We talked about that earlier. So if you have, you know, documentation from
the previous setting that it’s 4 and your nurse goes in and looks at it and they’re
like it’s 4 not a 3. But you have documentation that says it was
a stage 4 it is a code and that’s what you will need to code. And it will be a healing 4. So clinically you maybe looking at something
that’s healing, that clinically looks to you like a stage 3. But we know that it’s worse stage was a stage
4. So until that is closed it continues to be
a stage 4. And then once the pressure ulcer is fully
granulated and the wound surface is completely covered with new epithelial tissue the wound
is considered healed and should no longer be reported as a unhealed pressure ulcer. So some of the questions and comments that
came up during the lunch break around this was, well, wait a minute. We used to code this, if it was a healed or
closed stage 3 or 4 we used to count that. And so the instructions here, you don’t count
that. Okay. Even though you know it. You clinically want a care plan for it. But we’re not going to count it if it’s healed
and no longer to be reported. So that’s a clarification point. So that’s a change in practice for your staff. You want to make sure that they clearly understand
that. A previously closed stage 3 or 4 pressure
ulcer, that breakdown again should be staged at it’s worse stage. So it was a 4. So let’s take that scenario of a person that
was a 4 maybe in the skilled nursing facility. It’s healing. Your nurses are looking at it. They’re like, wow this is great. It’s healing beautifully. It’s still a stage 3, okay. But let’s say during the care it completely
heals, which would be awesome. It closes. And then if it should open again — so it
closed over. And now it opens again. It goes right back to being a 4, okay. Maybe it looks like a 2 to you or the nurse,
or back to that 3. But it goes back to — because we know it
was originally a stage 4. If the pressure ulcer was unstageable for
any reason at the most recent SOC/ROC do not consider it new or worsened if at some point
between the SOC/ROC and discharge it became stageable and remains at that same stage at
discharge. So let me explain this one a little bit. So a patient comes in. They have a wound, let’s say that’s covered
with a eschar. We don’t know what it is. So it’s unstageable due to eschar, right,
slough or eschar. Now while they’re in care, they’re not discharged. You’re still caring for them. Let’s say you do some sort of chemical debridement. It now — the slough’s gone. And you can stage the ulcer. So you stage that ulcer. Let’s say it stages out as a 3. So now it came in covered in slough and eschar. So it’s unstageable. We’ve chemically debrided it. It is a stage 3. At discharge it’s a stage 3. We’re not coding that as worse. Because from the fact is, we didn’t know what
it was when it was covered with eschar right. We didn’t know what that wound was. As soon as it was cleaned up we knew it to
be a 3. But let’s say it came from the previous setting
and it was a 4. It’s always a 4. Do you see what I’m saying with that? But let’s say it developed in the nursing
home and it came and it had slough or eschar and it hadn’t cleared. They couldn’t stage it. It was left as a unstageable for them. It came to you as a unstageable. You’re able to chemically debride it or debride
it, whatever happens. You now know it’s a stage 3. You code it as a stage 3. If at discharge it’s a stage 3 it’s not considered
worsened. Do people understand that? Okay, good. If the pressure ulcer was unstageable at the
SOC/ROC then was stageable at a routine visit or follow-up assessment, and by discharge
the pressure ulcer had increased in numeric stage since the routine visit and follow-up
assessment it should be considered worsened. So now let’s go through that same scenario. They came in with eschar, okay. You cleared it. It became a stage 3. During the care, so you identified the stage
3. During their care or their episode of time
that they’re with you it gets worse. It now go to a stage 4. You would then code it as worsened, okay. Because it declared itself once you cleaned
it as a stage 3. But it continued to deteriorate and we ended
up with a stage 4. It then would be considered worsened. Everyone get that? Yes, okay. Good. If a previously staged pressure ulcer becomes
unstageable then was debrided sufficiently to restage by discharge, compare its stage
before and after it was deemed unstageable. If the pressure ulcer stage has increased
in numeric staging report this as worsened. So what we’re saying, let me translate this
for you. So they get admitted into your service and
they have a stage 3 pressure ulcer. Clear, stage 3. During the time on service it gets — the
wound gets covered with let’s say eschar again, completely covered. So now it’s unstageable. So then they continue on. You treat it. The eschar and the slough is removed and now
we have a stage 4. It’s considered worsened. Okay. Because it progressed. Slightly different scenarios. One I gave you they came in with that unstageable,
right, the wound. Then it progressed. Here it came in, you knew what it was. It became unstageable. And then when the slough and the eschar was
cleared from it, it now was worse and increased in stage. So in fact we would consider it worsened. Then the last one the pressure ulcer that’s
unstageable at discharge due to a dressing device such as a cast that can not be removed
to assess the skin underneath can not be reported as a new or worsening unless no pressure ulcer
exists at the site at the most recent SOC/ROC. So for example, if I had a stage 2 pressure
ulcer and you had let’s say some sort of a removable cast and you could get in there
and you could look at it, and by discharge they’ve now put on a cast that you can’t take
off and look. You can’t say that it’s worse. You don’t know. You have to code that as unstageable due to
removable device or dressing and it’s not considered worsened. Because we don’t know. It could still be a stage 2 underneath that. It could have healed. Who knows. So these are slightly different caveats. But they’re important subtleties within the
coding of these particular items. So I would take the opportunity, especially
since these — two of these items are new for you and make sure that you do education
and training with your staff. And of course you know all the various data
sources, observation, medical record, physical assessment, clinical record. And you can go to Chapter 5 of the OASIS Guidance
Manual to get some more scenarios around that. But now let’s take the opportunity to look
at some quick practice scenarios. And I think these are still in your same packet
that you already had taken out. We’re going to look at some of the new practice
scenario under 1311 and 1313. So just, you know, continue to progress in
your little packet there. So let’s look at the scenario we have now. So a patient develops a stage 3 pressure ulcer
during their home health quality episode. The wound bed is subsequently covered with
slough, hence the pressure ulcer becomes unstageable. The patient record indicates the wound debridement
was performed on the stage 3 pressure ulcer two weeks prior to discharge. During the discharge assessment the wound
bed was observed and numerically staged as a stage 3. So, let’s take the opportunity to code this. So you have your scenario on the top of your
coding sheets. Again for those of you that are watching livestreaming,
think about how you’d code this. Okay. All right. I’m looking around. I think most of the room is done. Hopefully those of you on livestreaming have
completed it. So let’s go through this scenario. So in this scenario the first question is
M1311B1. So we didn’t do the whole assessment here. We carved out pieces of it, just so you know. But for this practice scenario, the number
of stage 3 pressure ulcers at the start of care the SOC/ROC? Correct. The patient had 0. So the next question says the number of stage
3 pressure ulcers at discharge? 1. Very good. Okay. So the next question that we’re asking ourselves
is the number of these stage 3 pressure ulcers that were present at the most recent SOC/ROC? 0. Okay. Good. Very good. And then the next question that we’re looking
at is worsening in pressure ulcer status since SOC/ROC stage 2? 0. Right. Worsening in pressure ulcer status since SOC/ROC
stage 3? 1. Worsening in pressure ulcer status — and
we’re going to go through the scenario in just a moment, okay. So stage 3 at discharge it’s a 1 how about
stage 4? 0. Okay, great. So then the next question we’re asking is
worsening in pressure ulcer status unstageable non-removable dressing? Right, 0. How about worsening in pressure ulcer status
unstageable due to slough or eschar? I’m hearing 1, 2, 0. Okay, most people said 0 and that’s correct. And we’re going to go through. Again we’re going to go through the rationale
shortly. And worsening in pressure ulcer since SOC/ROC
unstageable deep tissue injury? 0. Okay. So let’s go through the rationale. So on the discharge assessment M1311B is coded
as a 1. And 1311B2 is coded as a 0 because the stage
3 pressure ulcer developed during the home health quality episode and was therefore not
present on the SOC/ROC. And I think you guys got that piece of it. And M1313B is coded as 1 on the discharge
assessment because the stage 3 pressure ulcer is noted on discharge. Okay. The ulcer developed during the home health
quality episode it was debrided and reassessed as a stage 3 therefore not worsened. However it is coded as a new pressure ulcer
because it wasn’t present on the start of care the SOC/ROC. Everyone got that one, why we would do that? Yes? Okay. All right. So that walked you through what’s the rationale
and why we coded what we did. All right. So we have another practice Scenario 2. And in this practice scenario we have a patient
was admitted to home care from the acute care hospital with two stage 2 pressure ulcers
with clear fluid blisters, one on each heel. After a few days the left heel stage 2 blister
had ruptured and presented as a shallow ulcer with a pink wound bed. The right heal continued to evolve, having
a blood-filled blister and matured in color from a red to maroon purple color with the
area surrounding the blister being boggy, painful and warm. The patient stated she was moving and going
to stay with her daughter who lives two hours away and she was discharged to another provider. Upon discharge the right heel had a shallow
ulcer with a pink wound bed. The left heel was covered with a firm dark
eschar with slight bogginess around the eschar. So we have our scenario? Okay. So now we have to code this person on SOC/ROC
and at discharge. So again we took a subset of the questions. I’ll give you just a moment. Okay. It looks like most people are done. So let’s look at this particular patient. The number of stage 2 pressure ulcers on your
SOC/ROC for this particular patient? Correct, 2. They had 2 ulcers. How about on discharge? The number of stage 2 pressure ulcers on discharge? Correct, 1. All right. The number of these stage 2 pressure ulcers
present at most recent SOC/ROC? Correct, 1. The number of stage 3 pressure ulcers on the
SOC/ROC? 0. Correct. The number of stage 3 pressure ulcers on discharge? 0. Good. Okay. The number of these stage 3 pressure ulcers
that were present on the most recent SOC/ROC? You guys got it. You got the skip. Again, within your automated system this would
just be a no brainer. This would skip you automatically. All right. So now let’s look at M1313A, worsening in
pressure ulcer status since SOC/ROC for stage 2? Okay. I’m hearing 1 and I’m hearing 0. And the answer is 0. Okay. And we’re going to go through the rationale
shortly. Worsening in pressure ulcer status since the
SOC/ROC stage 3? 0. Good. And then worsening, let’s see for — since
SOC/ROC stage 4? 0. Good. Then we have, let’s see, worsening in pressure
ulcer status SOC/ROC unstageable non-removable dressing? 0. Very good. And now, how about worsening in pressure ulcer
since SOC/ROC unstageable due to slough or eschar? 1. Great. And worsening in pressure ulcer status — since
SOC/ROC unstageable due to suspected deep tissue injury? 0. Right. Okay. So let’s go through quickly the rationale. 1311A stage 2 would be coded as 1 at discharge
at the right heel remain as stage 2. Right we had the 2 heel ulcers. One went to status stage 2. And 1313E unstageable due to coverage of wound
bed by slough or eschar is coded as 1 since the left heel which was a stage 2 on the SOC/ROC
is now worsened to unstageable due to eschar. A stage 1 or 2 pressure ulcer is also considered
worsening if covered by slough or eschar as it is now at least to stage 3. So that’s a subtly that some groups have struggled
with. So we know that if it’s a stage 1 or 2, it
can not — the second it has slough or eschar, it’s automatically a 3, at least a 3. Because a stage 2 can’t have slough or eschar. We know it’s worsened. Again these are subtleties, but things to
practice with your staff. The last scenario we have, last of I think
our scenarios. This is practice scenario 3. A patient is admitted to the home care with
two stage 2 pressure ulcers. A mutual decision was made to transition the
patient to hospice care. By the time of discharge, the two pressure
ulcers had merged and increased to a stage 3. So let’s go ahead and answer and code these
for this patient. Okay. Are we ready? All right. So let’s look at this particular patient. The number of stage 2 pressure ulcers at the
SOC/ROC? 2. Good. The number of stage 2 pressure ulcers at discharge? 0. Right. The number of stage 2 pressure ulcers present
upon — were present at most recent SOC/ROC? Very good you guys are awesome. Number of stage 3 pressure ulcers at the sock
ROC? 0. Good. The number of stage 3 pressure ulcers at discharge? 1. right. Exactly. The number of stage 3 pressure ulcers that
were present on the most recent SOC/ROC? 0. Right. Very good. 0. So they didn’t have that. Right. Very good. Then we have worsening of pressure ulcers
since SOC/ROC stage 2? 0. Okay. So then we have worsening in pressure ulcers
since SOC/ROC stage 3? 1. Right. And then how about stage 4 SOC/ROC stage? 0. How about worsening pressure ulcers due to
unstageable non-removable dressing? 0. How about unstageable due to eschar and slough? 0. How about the last one due to suspected deep
tissue injury? 0. Okay, great. So at the time of discharge the two stage
2 pressure ulcers that were present upon the SOC/ROC merged to increase to one stage 3
ulcer. Therefore M1311A1 is coded as a 0 and 1311B1
is coded as 1 at the discharge assessment. Since the two stage 2 pressure ulcers merged
to stage the 3 the ulcer is no longer considered as present at start of care. So on discharge M1311B is coded as a 0. Since the two stage 2 pressure ulcers merged
and worsened to one stage 3 pressure during the home health quality episode, 1313B1 should
be coded as 1 on the discharge assessment. So who’s brain dead? We say at work my hair hurts. So this is tedious type of training. So what I’d like to do in summary is that
the quality measures for pressure ulcers that are new or worsened have multiple covariates
for risk adjustment. We’re going to hear about some of those covariant
areas, the lying to sitting on the side of the bed, which is GG0170C. And then we have M1620 bowel incontinence,
M1028 active diagnose, and M1060 height and weight. It’s important to understand how M1313 is
used in the calculation of the quality measure and the OASIS-C2 changes. So specifically Roman numerals replaced by
Arabic numbers. Each M1311 response now has two parts. And two additional unstageable categories
were added to M1313. So these are the general kind of things that
happened. Now I think you an opportunity to — what
we call our Action Planning you have in your folders an Action Plan. For those of you on livestreaming you can
download the Action Plan or you can just jot in your pad, in your office or whatever, saying,
what do I need to do? So I’ve just listened to Ann Spenard speak
for two hours. And we talked about wounds. And a lot of this stuff we probably have been
doing for a long time. But does my staff really understand all the
subtleties? Do they understand how this is going to impact
my quality measures? There are some very specific changes. How am I going to go back to my agency, my
organization and train on these? So ensure that the agency has a process including
tracking of all pressure ulcers, and change in pressure ulcer status in the patient record. You may want to look at your process of getting
information from the previous provider, especially if there’s pressure ulcers involved. Are you getting the data that you need? Are you getting the staging of the worse staging
for any particular ulcer. You want to review the current way you’re
documenting pressure ulcers in all your OASIS time points. So what’s your systems? What are your processes? And do all of your nurses know how to do that? You want to review and update your tracking
process to include the three unstageable pressure ulcer categories because two of them are new. And then I think the greatest thing is practice
a variety of scenarios with staff. And you can take all the ones that we have
here will be posted with the answers up after the training. So you will have all of this training material. So you can just take anyone of these scenarios
and just hand them out and say this week try this scenario. That week, try the other. Let’s get your answers in. You can use things like Survey Monkey. You can do a variety of things creatively
if you have staff kind of all over to make sure that they are understanding these changes. You want to make sure that you’re having the
discussion with your staff and be prepared to move forward. Or take cases in your own company. What kinds of complex things are you seeing? What kinds of questions are your nurses having? And maybe take some of those case scenarios,
write them up and use those as training. Very, very helpful to do that. There are a variety of resources that you
can go to. The OASIS education coordinator, there’s a
link there, Home Health Quality Reporting, the QTSO help desk, so you can ask questions. And certainly you can ask questions here. So I’m actually running out of time. I do have some questions, but I think we’re
going to try to get to those at the end of today. And so if any other questions come in, we’ll
take those. We’ll try to answer as many as we can today. And I think we have a question and answer
first thing in the morning tomorrow. The idea is to get as many of these questions
answered for you so that you have the clarification, and can take them right back to your organizations
and whatnot. If not, we’ve made a commitment to answering
— Some of these questions we’re like, wow, a little thought provoking. Let us think them through a little bit more. And if we can come up with those answers by
tomorrow, we will. Otherwise some might take a little bit longer
opportunity for us to go back, kind of do some due diligence and make sure we have a
clear and concise answer. And then those answers will be made available
as quickly as possible so you can use those for training. We had a lot of information. I have like 1 minute left if there’s a burning
question. If you go to a mic that would be great. Otherwise if you can submit them electronically
or hand-write them. And we will try to recap as many of these
questions this afternoon. We’re fighting, okay. »» Quick question. You had said that if someone was a 2 and they
went to a 3 within the five days from doing the OASIS that you coded them as a 2, correct? »» Yes, that’s a good question. Actually that came up as one of the questions. So the idea behind this is, if you go out
— so you have a 5-day assessment period. And your initial — let’s say you’re out there
within 24-hours. Your first assessment — and it’s very clear. »» I understand that. My real question is, if it comes in as being
unstageable with a dressing over it and then within the five days we know that it’s a 2,
do we do it as an unstageable, or do we do it as a 2? »» So the guidelines that we’re giving here,
and I’m going to clarify with Terry, right, that we are going to do. It would be, do your first assessment. So if it was unstageable due to a cover dressing,
then it would be unstageable due to a non-removable dressing. (low audio) I’m sorry? That’s because of — if you can go up to the
— first of all people can’t hear you on the streaming video. »» I was just saying that the variation
is because of the one-clinician rule. But if I’m the nurse that went on day one
and I go back on day five, I change that information. But if another nurse goes —
»» So I will tell you for this, for consistency across all of the care settings, that what
we are teaching, and what CMS has asked the messaging to be is, the first time that you
do your skin assessment to be whatever you’ve coded. Whatever you see, that that is what you should
encode on your assessment. Okay. It has nothing to do with like other rules. It’s whatever the first assessment is that
you’ve done. And that allows for consistency. That is how we’ve been teaching this in all
of the care settings. And I think that I hit that in the beginning
where we have, you know, people who are there when they’re in a skilled nursing facility,
the inpatient rehab or whatever. They could be looked at three times a day
with their skin. So we really want to capture whatever it is
in the first assessment. »» This will be a really quick comment. Earlier in one of the slides you were talking
— this is the change I think we need to highlight is the — if a pressure ulcer is then treated
with a skin graft, »» Uh-huh
»» That it becomes a surgical wound. »» Yes. »» That is different guidance than what
we’ve had in the past. So I just want to make sure everybody caught
that. Because we went over it pretty quick. »» Yes. Yes. So very good point. And that’s in the slides that if you have
a flap, or you have graft of some sort, that pressure ulcer goes from being a pressure
ulcer to now a surgical wound. It does not go to a surgical wound if you
just debride the pressure ulcer. That’s the fine line there. But it does go from a pressure ulcer to now
a surgical wound and stays a surgical wound until it’s healed. I can take one quick question, if you go up
to a mic. That’s the only thing I ask. I’m sorry to make people get up. Then I’m going to get the hook because I’m
going to run into the next person’s time. »» Jill, Healthcare Compliance Services
on the debridement question. We’ve always been instructed that if it’s
an excisional debridement that it’s a surgical wound. That doesn’t apply? »» No. No. If it’s a surgical debridement — so the guidance
that we’re giving, if it’s a surgical debridement of a pressure ulcer, it still stays as a pressure
ulcer. It goes to a surgical wound if we do a flap,
a graft or something else. Then it becomes a surgical wound. So yeah, there’s these little subtle things
that are going to be really important that you educate your staff on. So I really appreciate those questions and
points. So if you think that we didn’t highlight something
clear enough, you want us to clarify or whatever with the Q&A, certainly put those in and we’ll
make sure that we highlight those. All right. Thank you very much, and I’m going to turn
it over to the next speaker.

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