Author Archive for Loretta Olsen

Are you paying attention to your case mix index?

What is Case Mix Index (CMI) and why, as a case manager, do I care what that is?  According to the Financial management for nurse managers and executives (3rd ed.), CMI is the measurement of the average severity of illness of patients treated by a healthcare institution.  Basically, CMI helps determine the dollar amount assigned to a diagnosis related group (DRG) for the Medicare population. Medicare assigns a dollar amount for every facility, which is partially determined by the CMI.

Hospitals use the CMI to determine the budget, and if the actual CMI is lower than the budgeted CMI, the incoming money for those DRGs will be less. This causes an imbalance in the hospital revenue. If the money isn’t coming in as planned, a financial fiasco can occur. Think of CMI as the yellow light that warns the hospital of any impending decrease in hospital income. The financial wizards and senior management monitor the CMI on a monthly basis.

Appropriate DRG assignment for each inpatient case impacts the CMI. This is another reason why complete and accurate documentation is important. Coders need thorough documentation to assign the appropriate DRG. Appropriate coding determines the DRG, and the average DRG weight determines the CMI. Case management and clinical documentation improvement specialists can help the coding team by ensuring documentation supports the appropriate diagnoses, which will lead to appropriate assignment of a DRG.

CMI is complex, but essential to the revenue survival of hospitals. CMI is used to adjust the hospital’s average cost per patient. CMS uses the annual CMI to determine the DRG amounts for the next year. CMI is a very complicated concept to grasp, but it is important to remember that CMI is a tool that is used to predict income, outlines patient types, and helps explain the cost of treating a hospital’s population. In the end it goes back to complete, accurate and timely documentation and appropriate coding practices.

Do you know what your institution’s budgeted CMI is and what your actual CMI is?

The physician advisor: An invaluable resource

If your facility does not have a physician advisor, my recommendation is to get one. The physician advisor at our facility is great. Dr. Jim Chambers is very knowledgeable, not only in the field of cardiology, but he is quite knowledgeable in the area of coding. Dr. Chambers has spend countless hours educating and assisting our hospital billing department in establishing correct billing codes.

Documentation is key in obtaining the appropriate billing code. Physicians work hard taking great care of their patients, but what they lack is being able to document everything they have done for the patient and the outcomes. Outcomes are essential in the world of coding. For example, when a patient comes in with an abnormal prealbumin level, the physician treats this, but yet sometimes only documents that the patient has malnutrition. In this case, the hospital is reimbursed at the lowest level for malnutrition.

The stages of malnutrition are based on the prealbumin level, so the physician needs to document what level of malnutrition the patient is experiencing as there is dollar difference in the different levels of malnutrition. Our physician advisor has been working with our physicians to correct this. [more]

What about those hospital discharges?

Who should be doing the discharge planning and who should be working with the patients and families to make sure the goals set for the patient are being achieved? Who is developing the discharge plan? These are all great and very important questions. Discharge planning should begin as soon as the patient sets a foot inside the hospital, whether that is just to the emergency room or is placed as an observation patient or inpatient.

This is another great reason for the admission case management model. The admission case manager begins the discharge assessment right at the time the patient is either placed in an observation or inpatient status. If the patient is discharged from the emergency room, our social worker works with the emergency room staff, patient, and/or families for appropriate discharge planning.

The seven day a week admission case management model at my hospital is guided by Imogene King’s Theory of Goal Attainment. This theory of goal attainment implies that nursing is to help people achieve, maintain or restore health through the mutual setting of goals (Hood & Leddy, 2006). The nurse and/or social worker and the patient come to agreement on a mutual goal to achieve; this brings the patient to the forefront and the most important being. There is interaction of the nurse/social worker and the patient in the appropriate environment that is most conducive of achieving the goal. Once the goal is agreed upon and set, the next step is defining what steps will be taken to reach the desired goal. Case management as it evolved became a process of assessment of patient needs (goal setting with the patient and or family), planning of care, arranging resources of services and ongoing coordination and evaluation of the care being provided.

Our model is successful because of teamwork. Our case managers and social workers work together with the patient and families as well as the other hospital disciplines, through interdisciplinary rounds to ensure that everyone is working toward the same goal for discharge.

Discharge is more than getting the patient out of the hospital door. It is making sure that the patient is going to a safe, agreed upon place with the appropriate resources available and in place. Successful discharges reduce those unwanted readmissions.

Reference:

Hood, L. J. & Leddy, S. K., (2006). Conceptual bases of professional nursing, (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

What do hospital case managers do, anyway?

This is a question frequently asked by patients, family members, physicians, and other members of the medical staff.

Many people think that case managers are discharge planners, and that the only time a patient needs a case manager is when he or she has discharge needs. Case management is much more than that. It is important that we make sure that, not only do patients and families know what case management is, but that the nursing staff members know also.

Case managers work in forces behind the scenes, much like the crowd of people in the Verizon commercials. Case management is a hidden resource for patients. Often, the case managers work in the trenches, with their heads in charts, communicating with an interdisciplinary team of healthcare professionals to make sure that the patient is moving smoothly through the continuum of care, and there are no delays or detours in their care. This is usually an unknown aspect of case management.

Hospital personnel and the public need to be aware that case managers are advocates for all patients; they ensure that their healthcare facility and professionals are doing what is truly right for the patient, in the right setting, receiving the most appropriate care, and in the most cost-effective manner. Case management follows the patient’s plan of care to make sure that it is appropriate and timely, that their hospital admission status is appropriate, that their discharge planning is initiated, and that goals are set to meet the discharge plan. It is imperative that the case manager build a relationship with the patient and their families in order to reach a mutual goal of discharge.

It is also important for the bedside nurses to know that case managers are an excellent resource for them in planning the patients’ care and goals. One thing I did at our institution while we were redesigning our case management model was to do a mandatory in-service to nursing staff on how case management affects not only patient outcomes, but the financial outcomes for hospitals.

At our institution this year, we included a station on case management and interdisciplinary rounds at the nursing annual competency testing. Case management had a display booth with information about what case management is and the importance of interdisciplinary rounds. We also had a test for the nurses to complete. The comments we received from staff were very interesting.

Does your institution do anything like this? Are you confident that nursing staff members truly understand what case management is?

And one more important question: Do your physicians really know what case management is?

In the wake of the RAC, don’t forget about Present on Admission (POA)

I’m sure everyone is aware of the Hospital-Acquired Conditions (HAC) the Centers for Medicare & Medicaid Services (CMS) announced would not be paid for beginning October 1, 2008. The 10 categories of HACs are:

(1) Foreign objects retained after surgery
(2) Air embolism
(3) Blood incompatibility
(4) Stage III & IV pressure ulcers
(5) Falls & trauma
(6) Manifestations of poor glycemic control
(7) Catheter-associated urinary tract infections
(8) Vascular catheter-associated infection
(9) Surgical site infection following: Coronary Artery Bypass Graft (CABG)—Mediastinitis, Bariatric surgery, and some orthopedic surgeries
(10) Deep vein thrombosis (DVT)/Pulmonary embolism (PE) following some ortho procedures.

When looking through this list of conditions, as healthcare professionals we realize there are steps that can take place to reduce and/or eliminate the possibility of these conditions, and then there are conditions that no matter what we do may unfortunately happen.

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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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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:

Has human communication been forgotten in the hospital?

As a hospital-based case manager, have you ever wondered if the right hand knows what the left hand is doing?

Every healthcare provider touts they are doing what is right for the patient, providing what the patient needs, with the goal being that of getting the patient ready for discharge. In reality, everyone is working independently of each other and in some instances you may find there is one interdisciplinary group working against another. As the director of case management, knowing the case management role is to provide collaborative care to patients in a timely and cost effective manner, I also know that it is essential for the entire healthcare team, including the patient, to have a common goal. It is also important to discuss the goal and the steps necessary to achieve the goal. One thing I have found is, no matter how big or small a hospital is, communication among interdisciplinary groups is almost non-existent; I think our great advancements of computer charting has made human communication unnecessary. [more]