Do you use case management protocol?
Every facility, it seems, struggles to ensure patients are being assigned and treated at the correct level of care designation. An even bigger struggle is making sure physicians are educated to choose the appropriate level of care, write an order, and document it at the time of admission.
Inpatient orders cannot be changed or written retrospectively by the physician. When physicians don’t document correctly, it impacts the facility and the patient in many negative ways. Some of the negative impacts are as follows:
- Patients who are placed incorrectly in observation status may not meet the three-day inpatient stay requirements for skilled nursing facilities (SNF), which means Medicare will not cover their stay in the SNF
- Patients placed incorrectly in observation status may be held liable, or billed differently, for hospital charges that would have been covered by CMS had their order been written as an inpatient
- If a patient is placed incorrectly in observation status, then by the time the order is changed for observation status, he or she may no longer meet medical necessity requirements for all DRGs that were present on admission. This may be held under harsh scrutiny upon review by RACs
- Patients placed incorrectly in observation status, but that met medical necessity for inpatient admission and recover quickly, will negatively impact hospital’s length of stay data
To combat problems with admission orders and physician education, some facilities use what is called case management protocol. This protocol was piloted by the Florida Medical Quality Improvement Organization (FMQIO) with 20 acute care hospitals to reduce inpatient admissions. The project called for a protocol that authorizes case managers to assign patients to observation or inpatient status. Results of the project showed a 67% reduction in the denial rate for participating facilities. This relative reduction in denial rates was nearly three times greater for the participating facilities as compared to the control facilities.
How has case management protocol spread since the pilot program in Florida in 2003?
While some QIOs in states outside of Florida have accepted case management protocol, CMS has neither accepted nor denied its use. Now, with transition to MACs, it seems there is even greater confusion.
Observation regulation specialist Deborah Hale, CCS, says, “Before implementing case management protocol, facilities should keep in mind we don’t have a definitive statement from CMS saying it is an acceptable practice.”
Hale is working to get an answer from CMS on whether this is acceptable, but in the meantime, does your facility use case management protocol? What obstacles have you had to overcome to do so?
Editor’s note: To hear first-hand experience from case managers who were part of the FMQIO case management protocol pilot program in 2003, tune in to HCPro’s live audio conference Case Management at Your Hospital’s Points of Entry: A Gatekeeping Process to Save Days and Dollars on Tuesday, February 24, 2009.
About the Author: Julie works in the case management market at HCPro, Inc. She works on all of HCPro’s product lines for case managers including books, audio conferences, journals, videos and an eNewsletter. To contact her with questions, comments, or to be a blog writer, email jmcginley@hcpro.com.
Linda Hogel | Feb 25, 2009 | Reply
We are in the process of developing our program for care managers to write the patient status. We have the backing of our QIO. Their comment was that although there is nothing from CMS indicating it is an acceptable practice there is nothing indicating it is NOT. I am very interested in being included in your response from CMS about this. I would also be interested in examples of policies and procedures from other facilities already using this protocol. Thanks.
Linda Hogel RN
Project Manager
Sandra McCune BSN, RN | Feb 25, 2009 | Reply
I would like to caution facilities that are considering this that the whole purpose of the Florida QIO was to reduce inpatient admissions (ie-costs). The nurse reviewer can only use screening criteria, while a physician reviewer can use a much broader view of medical necessity to make the status determination. Unless you have secondary review by a physician for every case that fails screening criteria, you have way too many inappropriate observations. And if you do have such PA review, what is the purpose of the CM protocol? We outsource our PA review to Executive Health Resources, and are very happy with the results.
Sandra McCune
UM Specialist
Susan Fucito | Feb 25, 2009 | Reply
I am also very interested in any response from CMS. Is the Case Management Protocol being used in other facilities for Managed Care Payers?
Susan Fucito, RN BSN CCM CPAR
Clinical Denials Specialist
Loretta Olsen | Feb 25, 2009 | Reply
We are actually implementing a seven day a week case management model in our hospital. I have 4 case managers, 2 social workers and have just added 3 admission case managers. We have implemented an admit per case management protocol. This is backed by our QIO. The physicians really like this model as well. Our admission case managers are notified of every ED and direct admission. The patient is placed in a temporary hold of observation, which allows them to be put in the computer and orders implemented. The admission case manager then applies our criteria (We use InterQual software) and then place the patient in the correct billing status (inpatient or observation). Our protocol is that the admission case manager has up to 24 hours to apply criteria. The admission case managers hours are 7:00 AM to 7:00 PM, so the criteria is actually applied within 12 hours. The admission case managers also do the medication reconcilliation, admission history, pressure ulcer assessment, and the initial case management assessment.
Loretta Olsen
Rita Johnston | Mar 1, 2009 | Reply
Putting patients in observation status until screening criteria is applied is an inappropriate practice according to the Medicare guidelines. This also affects the accuracy of length of stay and may interfere with the three midnights required for SNF admissions. The level of care should be based on the medical necessity, severity of illness, and intensity of services required to appropriately treat the clinical status of the patient. This is one of the reasons that I question the validity of using an ‘admit to case management’ protocol. I have heard EHR representatives speak of this and their take on it is that observation status is overused.
Jenny Stelzner | Mar 3, 2009 | Reply
A question about Loretta’s post: If the observation bed is considered a “temporary” placement until case management can place in the correct admission status, can the admission be backed up to the initial day of admission, if the patient meets inpatient criteria?
Lee M. Berry, LGSW | Mar 4, 2009 | Reply
Loretta,
Who is responsible for your core measures? Who takes care of UR? Please share a sample of scheduling for 7 days with the CM Dept.
Our Dept explored a plan for 7 days and 12 hour shifts. We still need ideas for scheduling.
Will the social workers be responsible for dc planning?
Sandie Villa RN HNC | Mar 4, 2009 | Reply
At our hospital, the patients that come through the ED/ER to the floor arrive as emergency status. The case managers and utilization managers share the responsibility of screening the chart for interqual guidelines. We either call the attending physicain, wait for his arrival or may leave a prompt with our recommendation of pt status. We work m-f, 8-5 and the majority of physicians are very open to our input. Our goal is to get the correct status as soon as possible.
Joan Lunebach RN CCRN | Mar 4, 2009 | Reply
At our hospital, as patients are admitted , the CM’s do a review with interqual, and recommend a change to observation status. We too, either call the physician ,ask the primary nurse to get an order,or leave a prompt. Our goal is to identify the appropriate status asap also. Please ad me to the list for more info.Thanks..
L.Taylor | Mar 7, 2009 | Reply
Please add my email to our list. We are considering use of the case management protocol in our facility – but agree with the above statements. It would be great to get a definitive answer from CMS as to if this is an acceptable practice. Thanks!!
Ricky Stachura,MSN | Mar 11, 2009 | Reply
we are a small community hospital, with a low volume the case management dept. accepts and screens all admissions for appropriateness and correct status we have developed a standing order sheet with the different status. ie inpatient, obs. or op spu. with a check box and physician signature line we speak witht he physicians at the time of the admission. fax the order to patient access dept and place a copy on the chart. there is no confusion as to status. the physicians are very cooperative and often ask our advice, they have no problem signing the status order. we have a very active physician advisor who is supportive and available here at the hospital or by phone.
Nancy Meadows | Mar 25, 2009 | Reply
I also have concerns regarding the provider that is routinely using observation status until screening criteria is applied. While the hospital may have the blessing of their local QIO, have then discussed with their local FI/Carrier/MAC?? QIOs are not involved in oversight of outpatient claims. Nor are they billing experts. Guidance should be coming from the appropriate Medicare contractor. Overuse of Observation is an inappropriate practice according to the Medicare guidelines and could easily fall into potential fraud and abuse.
Chris Myers, RN | Mar 25, 2009 | Reply
We implemented an admit to case management protocol almost two years ago. It has worked well, reduced our inappropriate one and two day inpatient stays, and been well accepted by our QIO. One year ago we began referring all Medicare patients that did not meet inpatient criteria (we use the Milliman Care Guidelines)to EHR. They upgrade approximately 50% of those that do not meet inpatient criteria by the case manager’s review. Since we do not place the patients in any status ‘temporarily’, the status assigned by the case manager starts at the time of admission. Patients are not placed into observation status until the case manager reviews the admission, applies criteria, and writes the order. Since our problem was physicians placing patients in an inpatient status inappropriately, this program has worked well for our facility.
Jane O'Brien Day | Mar 26, 2009 | Reply
Joan,
Thinking of you. Do you remember me?
Vivian Street, RN, BSN, CCM | Apr 3, 2009 | Reply
Our facility is currently evaluating whether to implement a case management protocol for admitting our patients. Does anyone have a policy they are willing to share?
Stefani | Apr 4, 2009 | Reply
Planning and executing an Admit to CM protocol is much more than a simple policy. First you must start with the Medical Staff by-laws and make sure they are revised to delegate patient status to the case mgr based on stated guidelines (Milliman or InterQual). Then you need to design structure and operations to apply the protocol. Only then can you write a P&P codifying it all.
The key to success and ease of operations, as many above have cited, is that the protocol is applied BEFORE the patient becomes a ‘head in the bed.’
Carolann Barum | Apr 17, 2009 | Reply
We implemented Case Management Protocol over a year ago. It has taken care of several admission issues regarding appropriate status.
My question is the way are policy is written: We assign status, but not within a 24 hour window. Patients are assigned to observation as a default status until we return on Monday or after the Holiday. I am trying to find a source that states or supports what we do in the delay of status is appropriate or not. Any one have any information regarding this issue.
Rita McCarty | May 21, 2009 | Reply
Sandra,
Can you please share more information about EHR for PA review? Has your facility performed a financial evaluation of the benefits from using EHR? Do you utilize them for RAC appeals?
Thank you,
Rita McCarty
Stefani | May 25, 2009 | Reply
The issue of ‘default’ status – whether inpt or obs has been a topic on many many blogs and there is a general consensus that it is a ‘foot shot’ since it could potentially result in gaps and missed opportunities. If you have to assign a ‘default,’ having it go to obs rather than inpatient is certainly preferable. But frankly, havidng it done correctly at the point of entry is the best bet. And no matter how small your hospital is (25 bed CAH for example), having an EDCM or other gatekeeper is a best practice to ensure medical necessity for all transfers, directs, ED and SPU, and PACU patients.
Joanie Lunebach | Mar 2, 2010 | Reply
Janie
I just noticed your note..Of course I remember you…I think of you often….write me on facebook, or my email. joanlunebach@hotmail.com