Archive for March, 2009
Audio update: Managing LOS
As pay for performance and Recovery Audit Contractor investigations gain a greater bearing on the amount and expediency of reimbursement, managing length of stay (LOS) has become even more crucial for case managers. While responsibilities of case managers expand, an important measure of success continues to be managing LOS.
Many case management departments look at meeting a target number of days a patient stays at a facility, however, evidence has shown this may not yield the best outcomes when looking to manage and improve LOS. Inova Health System in northern VA, has had immediate and sustained success in reducing LOS through targeting clinical milestones. Its focus has been on improvement of the patient’s condition and minimization of avoidable complications, resulting in improved quality of care and a proven reduction in LOS.
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Discharging planning: When an LTACH makes the most sense
I recently received this question from a colleague:
Mrs. B is expected to need acute care for three to four weeks. There is a bed in a licensed Long Term Acute Care (LTACH) hospital but the family refuses that placement, since it’s an 80-mile drive. We don’t know what to do.
To answer your question: This issue is best resolved with the Utilization Review chairperson (a physician) who works with the patient’s physician. Here are two references: the Social Security Act for Discharge Planning and CMS-10, the Medicare Hospital Manual. In section 290.3 section C of CMS-10, it reads:
CMS, RACs, POA, LOS–but what about the patient?
Boy is healthcare ever on a fast track and getting more complex and confusing. There are new and revised regulations coming from the Centers of Medicare and Medicaid Services (CMS), and the Recovery Audit Contractor (RAC) implementation has us going to more meetings than we know what to do with. Let’s not forget about Present on Admission (POA) and we need to be monitoring those lengths of stay (LOS). Don’t get me wrong, these are all very important, high priority issues, but what about the patient?
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What is the main role of the ED case manager?
Hi. My name is Peter Moran and I have been asked to do a monthly blog on emergency department case management. I am currently employed as a ED nurse case manager at Massachusetts General Hospital in Boston and have been in my current position for the past 7 1/2 years. My hope is to allow an avenue for people to pose questions regarding ED case management and share my insights with others as well as gain insight I can incorporate in my daily practice.
I recently received the following inquiry:
What should the main role of the ED RN case manager be? If the hospital you work in does not have a UR team, and the majority of the admissions come through the ED, should the ED CM be solely focused on UR and making sure admissions meet criteria? Just curious of what feedback I will receive.
Thanks, Shannon
Admitting patients to “inpatient status”
I received a question recently about admitting patients to “inpatient status.” This was specifically related to a patient who is in the Emergency Department, and a physician writes the order “admit to inpatient;” the patient remains in the ED waiting for a bed (they may be considered an ED boarder).
From what I found in the reference below–found on the CMS website–the patient is considered “admitted to inpatient” when the order is written (dated and timed). For patients in observation being admitted to inpatient, this fact can have an impact on whether he/she was on the midnight census of the admitting date – which can then count toward the 3 day acute inpatient day making him/her eligible for extended care benefits.
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Patient safety month: Free tips and tools
March is patient safety month, and to celebrate, below are some tips for hospitals to increase patient safety from the Agency for Healthcare Research and Quality (AHRQ). Use these tips to educate your staff, or to pass on to others.
- Assess and improve your patient safety culture. AHRQ provides a free survey tool along with an entire toolkit.
- Build teamwork and communication. Communication between hospital staff is vital for ensuring patient safety. AHRQ and the Department of Defense have created a customizable, evidence-based toolkit to increase effective communication and other important teamwork skills in any healthcare setting.
- Limit shifts for hospital staff, if possible. Evidence shows shorter shifts (less than 12-16 hours) can reduce medical errors.
- Use reliable decision-support tools at the point of care. Ensure that computerized physician order entry or personal digital assistant-based drug information is readily available at the point of prescribing or ordering.
- Set up a safety reporting system. AHRQ provides additional research and advice on how to implement a Web-based safety reporting system in the ICU.
- Minimize unnecessary interruptions. Reduce distractions faced by the nursing staff, especially during critical times such as shift changes. Encourage staff to speak up when necessary, but create a “zone of silence” near medication preparation carts and other areas where concentration is essential.
For the entire list of tips and available tools, visit the AHRQ Web site.
Inpatient or observation, now that is the question
Just as you get your processes and procedures in place and staff trained on what is Observation and what is Inpatient, along comes Medicare! For acute care hospitals, how do we know if a patient should be Inpatient or Observation? First, and most importantly, you must have consistent processes and criteria to appropriately and proactively establish the appropriate placement of patient.
Here are a few questions to ask when determining the Medical necessity and appropriate status placement:
University of Chicago’s ED diversion plan scrutinized
The American College of Emergency Physicians says the University of Chicago Medical Center’s (UCMC) new diversion plan for its ED—moving patients with non-urgent needs to community hospitals and clinics—comes dangerously close to violating the Emergency Medical Treatment and Active Labor Act (EMTALA).
EMTALA dictates that hospital emergency departments provide emergency treatment to patients, regardless of the patients’ ability to pay. The complaint comes afterUCMC sent a patient who was attacked by a pit bull to another hospital for surgery. The American College of Emergency Physicians argues this practice comes dangerously close to “patient dumping.”
But UCMC maintains that its program is designed to treat patients at the appropriate location in a tough economic atmosphere.
Source: Chicago Tribune
Do you consider UCMC's program to be patient dumping?
Challenges for case managers in discharge planning
Discharge planning is a constant state of mind for our case management team. We continually strive to create a plan that is safe and comprehensive.
Discharge planning is also a major focus of accrediting agencies including both The Joint Commission (formerly JCAHO) and the Centers for Medicare & Medicaid Services (CMS). Our case management team has found that creating a safe discharge plan and initiating a thorough multidisciplinary assessment (including functional, psychological, and cognitive) within the first twenty-four hours has been a challenge. The challenge in safe discharge planning is usually the coordination of critical communication of all team members.
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Case managers doing more with less as the economy falters
It should come as no surprise that case management–a profession borne from the need to combine quality patient care and effective cost management–finds itself on the front line of the our nation’s financial crisis. Healthcare facilities across the country are seeing their financial resources under assault in a multitude of ways, including significant reductions in state and federal funding for Medicaid and Medicare reimbursement, declining endowments and donor contributions, and increases in charitable care. [more]
