Archive for June, 2010

What the EHR means to case managers

The Office of the National Coordinator for Health Information Technology (ONC) has released a final rule establishing a certification program for health information technology. The rule released June 18 describes the temporary certification program for electronic health records (EHR) and what organizations must do to be authorized to test and certify EHR technology, according to an HCPro.com article.

As a busy case manager you might think “well, that’s nice, but what is the big deal about the EHR?”

Most case managers have more work than they can handle and no time to think about their facilities’ adoption of EHR. Some case managers probably doubt that EHR will make their lives any easier.

Actually, case managers are invested in use of EHR. I want to share information compiled in a 2006 study by Eclipsys Systems entitled Eclipsys EHR Success Case Studies: Improved Operational Efficiency with an EHR. I don’t endorse a particular product, but I think this information demonstrates how EHR affects case managers.

The study found that EHRs helped:

• Reduce the need for full-time case managers while also increasing the number of reviews completed.
• Improve the process for managing concurrent denials because they allow clinicians to review medical records in their office or other locations within the hospital.
• Decrease the number of denials due to better management of avoidable days
• Improve staff effectiveness. Staff can access the entire chart and prioritize their workload.
• Enhance the ability to perform trend analysis by avoiding the need to manually enter data into an Excel® spreadsheet.

Users also commented that EHRs save time, reduce missed orders, provide better and safer care, and improve communication with physicians with legible notes.

While I wonder whether EHRs will reduce the need for full-time case managers, it would be wonderful if case managers had more time to focus on Medicare admissions, especially with increased scrutiny from government auditors. It also makes sense that legible records will reduce confusion and time spent verifying orders and outcomes. Also, EHRs with built-in utilization criteria may help providers reduce concurrent denials.

The ability to perform concurrent trend analysis with an EHR will allow case managers to actively prioritize their reviews and work more efficiently. Case managers could focus their time and energy on cases that need intervention most, which could reduce denials, improve quality of care, and increase cost effectiveness.

Case managers should be active participants in their organization’s process of reviewing and rating prospective EHR systems. EHR technology should facilitate communication between case management and computer-assisted coding software.

Case managers should be involved in all process improvement initiatives as payers move toward pay-for-performance reimbursement models. There are exciting opportunities for the practice of case management in the digital era.

Case managers descend on Capitol Hill

Members of the American Case Management Association (ACMA) returned to Washington DC last week to speak with lawmakers about hospital case management interests.

ACMA members first visited the nation’s capital last September. They discussed transitional care services, readmissions, and comparative effectiveness research in more than 40 meetings with members of both houses of Congress.

Twitter subscribers can read the ACMA members’ updates from last week’s two-day event at http://twitter.com/theacma. Read more about ACMA’s ongoing public policy efforts at its website.

The ACMA Public policy committee wants to hear from you. If you have any suggestions regarding case management’s involvement in health care legislation and public policy, contact Tyler Neese at the ACMA National Office tneese@acmaweb.org.

A holistic approach to ED case management

The emergency department (ED) operates 24 hours a day 365 days a year. Providing unscheduled episodic care requires close monitoring to ensure economic viability because of the volume of uninsured/underinsured patients and third party payers’ penchant to deny payment for services they believe lack medical necessity.

The ED is a major source of inpatient admissions and serves as the fundamental base for establishing medical necessity. An ED case management model promotes complete and accurate clinician documentation in the health record and establishes a foundation for promoting proper inpatient admissions.

The decision to admit a patient to the hospital is complex. The right decision requires that  hospitals embrace physician clinical judgment, clinical acumen, and medical decision-making far beyond admission screening criteria. Consider the following excerpt from Chapter 1 section 10 of the Medicare Benefit Policy Manual:

The physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s by-laws and admissions policies, and the relative appropriateness of treatment in each setting.

Factors to be considered when making the decision to admit include such things as:

• The severity of the signs and symptoms exhibited by the patient;
• The medical predictability of something adverse happening to the patient;
• The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and
• The availability of diagnostic procedures at the time when and at the location where the patient presents.

Practical incorporation of documentation principles

In a previous blog, I discussed the merits of specific, accurate, and detailed clinical documentation that reflects patients’ severity, acuity, risk of morbidity and mortality, as well as physicians’ clinical judgment, clinical acumen, the amount of work performed, and clinical medical decision-making.

Taking one step back, let’s approach clinical documentation in the mind of the physician. The patient receives an appropriate EMTALA screening and subsequent care begins.  [more]

Conduct a cost benefit analysis to improve care

Hospitals are under immense scrutiny to keep costs at an all-time low. Most case managers and social workers understand the various payment methods, especially case rate or DRG-based payments. Unfortunately, directors often don’t help their case management teams understand the difference between charges and costs; we also don’t explain how to use this information to change the situation on the floor.

A case management team that knows the costs of a room and basic services can determine whether a patient who doesn’t meet inpatient criteria should move to a more appropriate level of care for the duration of the hospital stay anticipated by the physician. This would improve care from both a medical necessity and economic perspective.

The following information is necessary to conduct a cost benefit analysis:

• The average cost of room and board at your facility
• The cost of any associated major treatments or equipment (e.g., ventilator)
• The number of days the patient is expected to stay in the hospital
• The cost of care at the proposed alternative level of care
• The number of days the organization plans to pay for care at the alternative level

First, multiply the room and board rate by the number of days the patient is expected to remain in the hospital. Be sure to include any associated major costs in the room and board rate.

Next, multiply the cost of care at the alternative level of care (e.g., SNF) and the number of days the organization plans to pay for care at that level

Finally compare the two amounts to determine which choice is more cost-effective.

Cost shouldn’t be the sole reason for placement at a lower level of care. List all non-financial reasons why the alternative setting will benefit the patient and hospital (e.g., avoiding hospital acquired conditions, family requests, etc.)

Transferring a patient from acute care to an onsite SNF or rehabilitation unit, when these options exist, may be appropriate and cost effective. If turf wars begin, a cost benefit analysis can resolve the conflict. It will demonstrate to the CFO that the cost of inpatient care is significantly higher than the cost of a lower level of care. This knowledge can promote proper intervention for the patient.

Other solutions exist for patients who are ready for discharge, but have nowhere to go. My facility had an Italian-speaking patient who was dying. We used a significant amount of resources to employ a telephonic interpretation service to communicate with him. The interpreter told us the patient simply wanted to die at home, in Italy.

Using a cost benefit analysis along with some creativity and influence, we were able to fly him home at minimal cost. The airline donated his ticket and a durable medical equipment company worked with us to minimize the cost of an oxygen tank. The airline returned the tank to the company on the return flight. We worked diligently with our risk management office to obtain all necessary signatures on various forms to eliminate any liability for the hospital and airline.

The patient’s family arranged for oxygen upon his arrival. The patient died four days later but he was able to spend his last few days with his family.