Q&A: Permanent remote CDI

Q: We are in the process of moving our CDI department to a remote work environment. The department is not new to this as we temporarily did this during COVID. However, we are looking at making this a permanent move. If you’ve gone remote, what hurdles did CDI teams and CDI leadership face? Were review rates/productivity increased? How were issues with CDI productivity handled? How do your CDI teams continue to engage providers? What things are you currently doing to keep the CDI team engaged? Any equipment issues or needs that were different from being onsite?

Response 1: I believe engagement is one of the biggest challenges with remote work. We tried to address that with increased communication via Teams meetings. We had biweekly team huddles, increased frequency of one on ones. Also utilized Teams format for chats allowing the team to ask others about topics they were struggling with on a case. We had some of our team that lived alone, and the isolation factor was definitely a challenge. Mental health check-ins are important. Another challenge was team members with children and family obligations often struggled with dedicated work time trying to balance family responsibilities and childcare.

As far as productivity goes, we did not change our expectations for review rates/productivity when we were working remotely. We ended up working remotely for 19 months before returning to a hybrid model in November 2021. When we returned, the team began to ask for lowered productivity because now they had to travel to the facility and had expectations of rounding and engaging with providers. Of course, they were doing all that prior to the remote work and keeping up with productivity. Looking back, it would have been smart to slightly increase the review/productivity rates in a remote model and then return to normal when working on site.

We now see remote work as a privilege that has to be earned and maintained. If an individual fails to meet productivity standards, they are required to return to campus and work onsite until they are able to consistently meet productivity. If that plan is not successful, we would look at education needs and/or a performance improvement plan.

Provider engagement when remote is tricky. The team was extremely successful in maintaining their provider engagement in the beginning of the remote work. I attribute that to the relationships they had established working onsite prior to COVID. As time went on and we had new CDI specialists join the team and new providers come on board, engagement was more of a challenge. This was the driver that we used to decide on hybrid versus a fully remote model. We also had a lot of feedback from our providers that they wanted that CDI presence. They like having a face to put with a name and that trust factor of knowing who is behind the query.

Fortunately, we did not have any special equipment needs when setting the team up remotely. They took their computers and dual monitors home with them. We then set up a workstation onsite that they rotate to when on campus. I would say one issue that came up was phones. Many of them preferred to use a hospital landline instead of their cell phones to talk to providers. With that, we loaded a phone app on the computer that allowed them to do phone calls online.

Response 2: We were completely onsite from 2009 to 2014 with paper charts and then transitioned to an EHR. Since 2014, we started working once a week at home. From 2016, we slowly made it a hybrid model—three days work from home and two days onsite and made sure at least one CDI specialist was available in the office by following a roster. We were planning to transition to complete remote in 2020 and when the pandemic hit, we decided it was time to go completely remote. Each staff member got to take a laptop, two big monitors, keyboard, and mouse home, so when they logged in it was exactly like logging in from their office without the VPN which made things easy for the staff. Also, we have seven hospitals in the area, so we had to give up our office space and just have three hubs for the entire seven hospitals should staff need to go in for power and internet outages.

We have weekly huddles with each team and discuss any ongoing issues and some education topics if needed. The leadership team would meet in person when needed to interview new hires with masks on. The CDI educator would do orientation for three days in person with a mask on and then remote one on one for 12 weeks.

We have monthly productivity numbers which would be sent to each staff member via email and touch base with them if they did not meet their goal for review rates, impact query rate, and total query rate.

When the CDI specialists query the physicians, they send an initial email to them about the query and also use Epic’s chat feature and real-time chat with the provider. After 48 hours, unanswered queries get on query escalation process, the manager runs the list every day at noon and sends it to the physician advisor, if the advisor does not get the escalated queries answered in 48 hours, it will get escalated to the CMO. This process seems to be working well at our three academic hospitals better than our four non-academic hospitals.

Now that all of us got our booster shots, we do monthly or bimonthly dinners with the teams and weekly huddles to engage them. We also have one on one calls if some staff need the extra nudge.

Our IT staff are good and handle the IT issues pretty well. For the past two years, we have successfully worked fully remote without many IT issues or the staff having to go into the office. 

Response 3: Some of our CDI specialists have had issues with being alone in the community without the support of each other, which has been a big hurdle for us. We use Teams and we taught the team how you can call each other or set up a meeting whenever you want or with whomever you want. We have a “Friday Flash” that goes out weekly to communicate weekly updates and of course monthly staff meetings. We have also instituted a brief weekly meeting at the community hospital.

All the CDI specialists have a hospital-issued laptop encrypted. If they chose to use their own desktop, that is fine if they use the encrypted software provided. We use a VPN too. We also use two screens, so a separate screen was provided.

We did increase productivity expectations; however, it is difficult for some to shut down after eight hours so that required constant leadership to not let burnout become an issue.

Our productivity metrics are based on the average of all the CDI specialists. We have monthly meetings with each CDI specialist and the director to go over productivity metrics. Any issues with productivity are discussed at these meetings.

We have committees—such as education, policies and procedures, newsletter development, research, patient safety indicators, etc.—that each CDI specialist is able to be on. We rotate these meetings after three months. We have become more engaged in the unit-based team meetings under the department of quality and safety. This has afforded us the platform for the physicians too.

Response 4: The first two CDI specialists of our team of six trialed working one week at home and one week onsite in spring 2018. The two CDI specialists were on opposite schedules, meaning while one was at home, the other was onsite. The trial proved that the CDI specialists were more productive when at home. By May 2018, each of our other CDI team members (one at a time) went home with no return to onsite. We have been successful and recently hired two more CDI team members who received their computers on the third day of working with us to go home. I orientated both through WebEx and they too are very successful.

When we transitioned to remote work, we did increase review rates, query rates, impact on severity of illness/risk of mortality and hierarchical condition category factor score, and financials.

Each team member has a monthly meeting via WebEx with our director to go over their metrics. There are times when a CDI specialist does not perform as they have in the past, but that is to be expected depending on the patient population you have for that month. Keeping each team member aware of their metrics monthly keeps them on task.

Our team has a great work ethic as they never want to return onsite, so they keep their head in the game.

We use Perfect Serve to stay in contact; we also can talk with them via telephone through the Perfect Serve app. We still have hospital phone extensions that are tied to our computer with use of a headset, so providers have our extensions on queries and are free to reach out to us at any time.

I am the face of CDI. I spend one to two mornings per week in the physician lounge discussing new medical guidelines and how the documentation needs to be aligned with the latest standard of care. I am also part of the sepsis task force team, so I am continually educating on the newest guidelines. I bring denials to the lounge and talk with providers who may have been involved in that case and how their documentation could have helped prevent that denial.

I meet one on one with the physicians and show them their cases and how different documentation could impact their patients. They love this process because we’re focused on their patients in real-time.

We also have a monthly onsite coder/CDI team meeting, and we invite a provider to discuss a new topic with the team which allows us to get their perspective and allows us to be able to teach the documentation side. We also have a weekly team meeting via WebEx and go over metrics, processes, educational finds related to ongoing audits, Guidelines and Coding Clinic, updates, etc.

We also celebrate successes a few times a year with a luncheon at a restaurant or catered into a conference center room.

One of my biggest pieces of advice is to allow your team flexibility while at home. Our team loves that. They start when they want and let me know if they will be away for any part of the day. The flexibility is what has made our team happy. They do their work but take a break if they have a doctor’s appointment, etc.

The CDI team are professionals, so we treat them as such allowing the work/home life balance. When home is good, productivity is through the roof.

In closing, my team will never be back onsite. They took our office space. I have a laptop in addition to my desktop since I spend one or two days a week in the physician lounge. Our organization is aware of our commitment to the organization and has supported my team any way they can. When your team is happy, productivity and your metrics will not be an issue. 

Response 5: We went remote in 2020 during the COVID pandemic. On top of that switch, we also experienced furloughs and mandatory paid time off for a week period. Staff members were on edge for sure. The mandate was that any “non-essential staff” should work remotely. It was abrupt and did not allow time for equipment requisition. We already had VPN in place and the ability to work remotely so most adapted quickly, utilizing their own equipment at home to sign into the system.

It was actually a big employee satisfier (parking at our hospitals can be difficult), and all wanted to remain remote. One challenge was to set up a work from home policy, determine equipment needs, and identify times when you may need to come onsite. Some of our older staff struggled with technology and Zoom, so we had to work with that group.

The staff requested to remain remote. They were informed that we could not show a drop in productivity. Our productivity and metrics actually improved considerably in a remote environment. Since a long commute was taken out of the equation, they were willing to put in more hours and meet their key performance indicators (KPI). Staff who were not meeting KPIs would be coached and then if they still weren’t meeting, they would have to come onsite. We have not had to have anyone come onsite so far.

While we haven’t changed our productivity metrics at this point, we did keep the data on productivity and KPIs prior to working from home and after remote work was established. We then shared that data with the C-suite. We were also asked to document how we were keeping staff engaged remotely. We had biweekly huddles, Zoom staff meetings with an icebreaker question to start off the meetings, education sessions with our CDI medical directors, and monthly joint CDI/coding education sessions.

We requested equipment for any staff that needed a computer or monitor. They took all of our equipment that was at the hospital, assigned it for use by our department, and set up times for staff to pick up equipment as needed.

We were asked to show how we were still able to engage with providers in a remote environment too. We did this by having a new provider orientation session on Zoom, attending provider service meetings both onsite and remote based on circumstances, one-on-one discussions with providers who were not responding to our queries via an escalation process, and educational videos published by our CDI medical directors.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and originally appeared in the CDI Leadership Insider, the monthly newsletter for members of the Leadership Council. For the purposes of this article, all Council member answers have been deidentified.