Recent Articles
Sneak Peek: A (controversial) case for ending the marriage between UR and case management
Utilization review (UR) and case management are as traditional a team as peanut butter and jelly. But some facilities are asking whether this longtime duo is really the best combination.
In what might be seen as a controversial decision, some facilities are now separating case management and UR.
This is a big change – UR has long been a major part of a case manager’s job description. But Riverside Medical Center in Kankakee, IL, is making the move. Its goal is letting case managers spend more time with patients and be, well, case managers, says Brenda Menard, director of case management at Riverside.
Further, Riverside wanted to allow case managers to not only spend more time with patients, but promote partnerships with their physicians for an efficient assessment of transition of clinical care. The organization now has a full-time certified insurance staff member performing UR, says Menard. Eventually, clinical documentation improvement staff may also be placed on each unit so they too can perform UR functions, she adds.
This article is adapted from an article which originally appeared in the April Case Management Monthly published by HCPro, Inc.
Understand home health rules for better care
For many patients, home health services can mean the difference between a successful recovery and a hospital readmission.
But, patients who need services go without because of confusion over eligibility requirements, says Jackie Birmingham, RN, MS, CMAC, BSN, vice president emeritus of clinical leadership at Curaspan Health Group in Newton, Mass.
“Hospitals are sometimes more restrictive than they need to be,” says Birmingham. And sometimes home health agencies are overly conservative out of fear that patients won’t qualify for services, says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of The Center for Case Management in Wellesley, Mass.
Patients ultimately pay the price.
Is this the case at your organization? It may be time to examine your home health policies and processes.
The government currently defines patients as “homebound” and eligible for home health services if they are only able to leave home infrequently for short periods of time, says Birmingham.
Patients are still eligible if they leave their home for a physician appointment, for example. But people sometimes wrongly assume that if they leave the home for any reason they don’t qualify, she says.
This post is an excerpt from the June issue of Case Management Monthly. Purchase the rest of the story.
News: CLABSI rates down 32%, says CDC
Twenty-one states posted decreases in central line-associated bloodstream infections (CLABSI) in 2010, according to a report from the Centers for Disease Control and Prevention. This translates to a 32% national reduction, which suggests that the national goal of reducing CLABSI by 50% by 2013 is within reach.
California, Massachusetts, Oregon, and Virginia are among the states posting CLABSI decreases. Only Arizona and Delaware reported increases between 2009 and 2010, while 20 states reported no change, including Indiana, New Hampshire, and Vermont. Seven states, including Alaska and Idaho, didn’t file a report.
Data was reported from January through December 2010; the referent period is January 2006 through December 2008. In all, 22 states and the District of Columbia require the use of the National Healthcare Safety Network, CDC’s healthcare infection monitoring system, for HAI reporting mandates.
Read more on HealthLeaders Media website.
Tip: Appeal to key decision-makers when advocating for transitions programs
There are some key factors to think about and plan for when implementing a transition program.
Beginning strategically, it is important to determine what your organization hopes to accomplish by implementing a transition program. This can help you measure success and justify future efforts. Suggestions have been provided for outcome indicators. However, a great deal of consideration must be given to the organization’s priorities.
Most organizational decision-makers will be interested in how a new program affects clinical, service, and financial outcomes. It is important toknow how your key decision makers will judge the program’s success.
Healthcare organizations will invest in a transitions program for a variety of reasons. In a managed care market, the financial impact of reducing hospital utilization is obvious. However, there are benefits even in a fee-for-service market.
Reducing emergency department overcrowding and making room for more profitable patients could justify a transition program in a hospital with high volumes. Reimbursement and the regulatory environment are providing increasing incentives for smooth handoffs, better communication among providers, and programming to improve patient self-management.
Softer, but no less important, are the contributions these programs make to enhancing an organization’s community image. Transitions programs can improve patient loyalty and relationships with other providers.
This week’s tip is adapted from Reducing Readmissions: A Blueprint for Improving Care Transitions, published by HCPro, Inc.
News: Preventing hospital readmissions takes a village
From Rockport to Yakima and from Detroit to El Paso, 30 community-based organizations (CBO) are joining hands with hospitals, finally, in a communal effort to prevent hospital readmissions, all funded by $500 million authorized by the Affordable Care Act for five years.
These CBOs are social support groups and Area Agencies on Aging, the type of quasi-government entities and non-profits historically known for home-delivered meals, transportation services, support, and counseling for seniors and the disabled. Now, these regional collaboratives are embarking on a variety of experiments to pick up the care of patients where hospital discharge planners leave off.
Projects were supposed to have started Jan. 1, 2011, but by fall none had been picked and few hospitals seemed interested. Health and Human Services officials lamented the paucity of applications. Hospital officials complained they didn't even know who their senior services organizations were or what they did because they lived in different worlds.
Read more on HealthLeaders Media website.
Patient-centered care redistributes responsibility
It was a wonderful and rare accomplishment. In 2008, a 23-year-old woman with severe cystic fibrosis successfully carried and delivered a healthy, full-term baby girl at Long Island Jewish Medical Center, in New Hyde Park, NY. Despite that major achievement, the complex regimen of daily medications that Christina Marie McDonald needed to manage her disease created challenges.
“On the maternity ward, no one understood anything about CF,” says Ruben Cohen, MD, director of the adult CF program and codirector of the asthma center for the 888-bed tertiary care teaching hospital. “She didn’t receive her medications when she needed them.”
The circumstances of McDonald’s delivery served to highlight an issue that hospital personnel had already begun to grapple with for adult patients with CF: how to deliver the same quality of care in the hospital that patients routinely administer themselves at home.
“After that experience, the patient’s father wrote a letter asking, ‘Why does the hospital tie our hands and put these routine measures in the hands of busy medical personnel when the patients and their families know the illness very well and are experts in their own care?’” explains Fatima Jaffrey, MD, director of outcomes research at LIJ Medical Center.
Caring for adult CF patients
CF is a genetic disease that affects approximately 30,000 Americans by damaging lung function and causing severe breathing problems and life-threatening infections. It also obstructs the pancreas and stops natural enzymes from helping the body break down and absorb food.
Long considered a pediatric disease—as recently as the mid-1980s, few patients made it past their teen years—medical advances have resulted in people with CF living increasingly longer lives, well into their 30s and 40s and beyond. As patients get older, however, the disease tends to become more complicated, according to Jaffrey, as does the regime of high-calorie supplements, antibiotics, digestive enzymes, and breathing treatments—as well as chest therapies—that patients administer to themselves every day at home orally or via nebulizer, IV, or stent, on both a scheduled and as-needed basis.
CF patients are routinely hospitalized once or twice a year for approximately two weeks for IV antibiotic treatments and are admitted through emergency departments for a variety of breathing, digestive, or infectious flare-ups. LIJ Medical Center admits between one and five CF patients a month, and upon admission, their medication routines were traditionally taken out of patients’ hands and turned over to hospital nursing staffs. The result was that patients waited for 15–29 hours for their first breathing treatment, 18 hours for their first round of IV antibiotics, and often missed snacks and meals because the digestive enzymes they needed were not delivered in advance of eating.
“Until 2002, all CF patients were admitted to pediatrics, no matter what their age, and adult hospitals were not used to CF patients and their regimens,” explains Cohen. “It all came to a head with Christina. That’s when we realized that it’s not the fault of one or two people who just don’t understand, but that we need a new way of doing things.”
Read the full story on HealthLeaders Media.
Audio conference: Utilization Review 101: Meet Requirements and Maintain an Effective Committee
A utilization review (UR) committee is not only a government requirement; it’s your hospital’s insurance policy against improper level of care determinations and denials.
Learn how to get physicians and essential team members to understand the need for a UR committee and engage in the process during HCPro’s May 15 audio conference, “Utilization Review 101: Meet Requirements and Maintain an Effective Committee.” Our expert speakers Deborah Hale, CCS, CCDS, and Beverly Cunningham, MS, RN, will outline government requirements, help you establish an effective UR committee, and provide best practices for meetings and action items.
After this audio conference, attendees will be able to do the following:
- Identify the regulations that govern the UR committee
- Establish an effective UR committee agenda
- Achieve physician buy-in on the importance and role of the UR committee
- Implement best practice into your UR committee
Find more information about this audio conference at: www.hcmarketplace.com.
Sneak Peek: Barrier reduction teams improve efficiency at New York-Presbyterian
If your facility has factors that slow down the patient discharge process, your frontline staff members likely have a good idea of the problems. However, frontline staff at most facilities do not have the means to communicate the problems or help make improvements.
At New York-Presbyterian Hospital in New York City, this is no longer the case.
Leaders there established multidisciplinary barrier reduction teams (BRT) in late 2009, which are designed to increase efficiency and improve communication at the organization. The teams give staff members a way to speak up about issues that may hinder patient care and the discharge process.
This article is adapted from an article which originally appeared in the May Case Management Monthly published by HCPro, Inc.
Helping CHF patients manage their condition and avoid unnecessary readmissions
When case managers are looking at patients who are frequently readmitted to their facility within 30 days of their last discharge, chances are they’ll find a lot of chronic heart failure (CHF) patients among them. That’s because CHF patients typically have a higher readmission rate than any other disease, says Jan Lear, RN, CMC, director of case management at MedStar Franklin Square Medical Center (MFSMC) in Baltimore.
Some of these hospitalizations are unavoidable as the disease progresses. But in other cases, helping CHF patients better manage their condition can keep them from needing an acute care admission.
At MFSMC, officials started an initiative in 2011 that has reduced unnecessary CHF-related readmissions from 10.2% to 9.5%. At a subacute care facility that has a CHF program partnership with MFSMC, readmission rates have dropped from 66% to 11% over the last 12 months, says Lear.
Other facilities are making similar progress. Jennifer Tatum, RN, a case manager at Mercy Medical Center North Iowa in Mason City, says although the exact figures aren’t in just yet, Mercy’s newly minted CHF program is getting results.
Purchase the full article that appeared in the April edition of Case Management Monthly.
Audio conference: Medical Necessity 2012: Case studies and top documentation risk areas
Medical necessity continues to gain national attention as Recovery Auditors scrutinize compliant patient status practices at facilities. Learn how your organization can effectively monitor medical necessity and avoid unnecessary audits during HCPro’s May 3 audio conference, “Medical Necessity 2012: Case studies and top documentation risk areas.” This 90-minute live audio conference will focus on top documentation areas for high-risk cases of audit and denial, and will describe real-life examples of successfully overturned medical necessity cases. Our expert speakers will also explain how to avoid medical necessity denials with a proactive approach. After this audio conference, attendees will be able to do the following:- Identify documentation necessary for cases at high risk for an audit, included drug-eluting stents, cardiology, and syncopy
- Explain how documentation for medical necessity and documentation for CDI coding differ
- Provide examples of successfully appealed cases
