CMS-10487 Sampling Procedures for Medical Record Review

ATTACHMENT C
SAMPLING PROCEDURES FOR MEDICAL RECORD REVIEW

A.

Sampling Approach
We will use purposive sampling procedures to select 10 patient medical records for review at each of three
facility types: IMDs, referring hospital ERs, and general hospitals (GHs) that admit Medicaid beneficiaries
experiencing a psychiatric emergency when no psychiatric beds are available. The total number of records
reviewed per state will vary based on the number of participating IMDs. For example, in states with four
IMDs, 120 records will be reviewed—10 from each of the four IMDs, and 10 from both an ER and GH
associated with each of the four IMDs. For states with only one participating IMD, a total of 30 records will be
reviewed—10 from each facility type.
Prior to the site visit, we will ask each facility’s point of contact for specific patient rosters, described below,
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from which we will select records to review. Purposive sampling will enable site visitors to identify medical
records for patients of particular interest, such as those with medical comorbidities or high-risk behaviors
requiring chemical or physical restraint, or those whose length of stay was greater than average for a
particular IMD.

B.

Sampling Procedure
In order to select samples of patient medical records, the procedures below will be carefully followed by site
visitors. A description of rosters needed from each facility type is provided, along with the number of patients
to be sampled from each roster.

1.

Roster Descriptions and Patient Sample Sizes by Facility Type
IMDs—The site visit team will request two different rosters of IMD patients. Each roster will include the
patient’s name, age, admission date and time, diagnosis, and the discharge date and length of stay
for patients who have been discharged. A total of 10 patients will be chosen from among the two
rosters, as follows:
•

Five patients will be selected from a roster of demonstration patients discharged 30 - 60
days prior to the start of the site visit (closed medical records).

•

Five patients will be selected from a roster of Medicaid beneficiaries who experienced a
psychiatric emergency and were discharged 30 - 60 days prior to the implementation of the
demonstration (closed medical records). Selecting closed medical records of patients
receiving treatment prior to the implementation of the demonstration will allow site visitors
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to assess changes in quality of care.

ERs—The site visit team will request two rosters from each referring ER that is visited. Selecting closed
medical records of patients receiving care at the ER prior to and during the demonstration will allow
site visitors to assess changes in the amount of time Medicaid patients spend in the ER, care received,
and discharge disposition. Rosters will include the patients’ name, age, admission date, diagnosis,

1

We will begin discussions with the states and facilities regarding any participant protection requirements well
in advance of the site visit to ensure adequate time to obtain internal review board or other approvals that may
be necessary.

2

If the IMD was not serving Medicaid beneficiaries prior to the demonstration, we will ask to review records
of non-Medicaid beneficiaries experiencing a psychiatric emergency.

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discharge date, and length of time spent in the ER. A total of 10 patients will be chosen from the two
rosters, as follows:
•

Five patients will be selected from among Medicaid patients discharged from the ER with
psychiatric emergencies 30 - 60 days prior to the start of the site visit.

•

Five patients will be selected from among Medicaid patients discharged from the ER with
psychiatric emergencies 30 - 60 days prior to the implementation of the demonstration.

GHs—The site visit team will request two rosters from each GH visited. The roster will include the
patients’ name, age, admission date and time, admitting diagnosis, discharge date, and length of stay.
A total of 10 patients will be chosen from the two rosters, as follows:

2.

•

Five patients will be selected from a roster of Medicaid beneficiaries with psychiatric
emergencies who were discharged from the GH 30 - 60 days prior to the start of the site
visit. If, as a result of the demonstration, fewer than 5 Medicaid beneficiaries with
psychiatric emergencies have been admitted to the GH, we will request to also examine
records for non-Medicaid beneficiaries admitted with psychiatric emergencies. If psychiatric
boarding in the GH has been eliminated, we will record the date of the last admission of a
Medicaid beneficiary for a psychiatric emergency, as well as the date of the last admission
for a psychiatric emergency of any kind.

•

Five patients will be selected from a roster of Medicaid patients with psychiatric
emergencies who were discharged from the GH 30 - 60 days prior to implementation of the
demonstration.

Sample Selection
Using the list of patient characteristics in priority order below, we will choose patients from each roster until
the sample number specified for the roster is reached. For IMD and GH patients, we will choose only one
patient from each category unless no patients exist in the other categories. For ER patients, we will select
patients with the longest length of stay. Although only the first category (length of stay) will be indicated
explicitly on the roster, we will review the roster with facility staff to identify patients with the other
characteristics.
31. Long length of stay (if the length of stay is abnormal or above average)
•

High suicide risk

•

High homicide risk

•

Medical comorbidities

•

Co-occurring substance use diagnosis

If multiple patients on a roster fall within a given characteristic category, we will use any other information
that is provided to select a patient that is a more complicated or unique case.
3.

Sampling Labels
To maintain patient confidentiality we will use a unique Mathematica numbering system to identify the
patients in our sample. The Mathematica number will indicate the state, type of facility (IMD, ER, or GH), and
a 2-digit suffix unique to the patient. We will identify IMD patients discharged 30 - 60 days prior to the site
visit by suffixes between 21 and 29, and IMD patients discharged 30 - 60 days prior to the demonstration by
suffixes between 31 and 39. We will identify patients discharged from an ER 30 - 60 days prior to the site visit
by suffixes between 41 and 49 and patients discharged from an ER 30 - 60 days prior to the demonstration by
suffixes between 51 and 59. We will identify Medicaid beneficiaries with psychiatric emergencies who were
discharged from the GH 30 – 60 days prior to the site visit by suffixes between 61-69 and Medicaid

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beneficiaries with psychiatric emergencies discharged from the GH 30 – 60 days prior to the implementation
of the demonstration by suffixes between 71 and 79. Site visitors will receive pre-numbered sample labels,
with several labels for each patient sampled. Site visitors will attach a label on the applicable roster next to
the patient’s name and will enter the number in the computerized record review data collection protocol.
The facility points of contact will be asked to keep rosters, with labels attached, for six months after the site
visit in case questions arise regarding the record review after the site visit is completed.

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