All Entries in the "Care Coordination" Category
Tip: Be sure the medical record contains all pertinent insurance information
Discharge planners generally are not involved in the registration process, during which patients identify their insurance coverage. However, it is not uncommon for clinicians to be made aware of erroneous or missing insurance information. For example, patients who are admitted through the emergency department are especially prone to errors or omissions in reporting insurance information. This can occur because the instability due to injuries or failure to locate their insurance card. This also can occur when patients are transferred from one acute care setting to another. Some other examples of sources of erroneous insurance information include:- Patients whose coverage has changed recently (e.g., a patient who recently turned 65 and is eligible for Medicare)
- Newborns not yet enrolled in their parent’s policy, especially when both parents work and have coverage; determining that parent’s policy is primary may depend of specific rules in each state
- Young adults enrolled in a parent’s health plan whose marital status changes
- Patients whose employers changed health plans during the same month as their admission
- Patients with preexisting conditions
Overweight physicians display bias in obesity care
Cheryl Clark, for HealthLeaders Media
Doctors who are overweight or obese are less likely than physicians of normal weight to diagnose weight problems with their heavy patients or to launch discussions with them about their need to slim down, says a Johns Hopkins report that its authors say is the first of its kind.
The report “indicates that if you’re a heavier physician you are biased when it comes to providing obesity care and that may be something physicians do not realize they’re doing,” lead author Sara Bleich, assistant professor of health policy at Johns Hopkins Bloomberg School of Public Health, explains in an interview.
“When they see patients who look like themselves—in that overweight or obese category—they think, ‘This person looks like me and I feel healthy, therefore let me focus on the more extreme’” complaints or issues they may have, such as diabetes and hypertension, rather than the underlying excess weight which may exacerbate their health problems.
Bleich’s paper was published in this month’s issue of the journal Obesity.
The paper is based on responses to 49 questions in a cross-sectional survey answered by 500 randomly selected primary care physicians—internists and general and family practitioners—who see patients at least 35 hours a week. They were drawn from the Epocrates Honors Panel of 145,000 doctors verified by the American Medical Association’s master file, and they received a $25 voucher for their time.
Read more on HealthLeaders Media.
CMS innovation advisors aim to improve quality of care
Margaret Dick Tocknell, for HealthLeaders Media
The Centers for Medicare & Medicaid Services has tapped 73 healthcare professionals for its innovation advisors program. Funded with $6 million from the healthcare reform act, the program is designed to help drive improvements to patient care and help reduce healthcare costs. A second group of 120 advisors will be selected in June 2012.
The program, which is managed by the CMS Innovation Center, includes six months of orientation as well as in-person national and regional meetings, virtual training sessions, and seminars and presentations by healthcare experts. Each advisor will receive a stipend of about $20,000 to help cover the cost of transportation, lodging, and other expenses.
This first group of advisors includes clinicians, allied health professionals, health administrators, physicians and nurses from 27 states. Each one is required to develop a systems improvement project that will be scalable to other areas.
Julie Lewis, vice president of health policy and government relations for Amedisys, will look at care management for high risk elderly patients. Tina Schwien, quality improvement consultant at Qualis Health in Seattle, is developing a project to engage patients and their families to help reduce hospital acquired infections.
Lewis, who works out of Washington, D.C., says her project is an offshoot of some work she did with Jeffrey Brenner while she was at the Dartmouth Institute for Health Policy and Clinical Practice. Brenner, a New Jersey physician, formed the Camden Coalition of Healthcare Providers to provide care management for vulnerable populations in the city. Lewis plans to take that effort a few steps further to test if care management for high risk populations can be sustained and replicated across a larger population.
The project will be based in Louisiana where Amedisys, a home health and hospice company, is based. Plans call for a hospital-physician partnership that initially will treat 50 to 100 Medicaid, Medicare Advantage and indigent patients.
New bundled payments initiative aims to lower costs, improve care coordination
Editor’s note: The following article is adapted from a blog Judith Kares, an instructor for HCPro’s Medicare Boot Camp® – Hospital Version, wrote for the Medicare Mentor website.
CMS recently announced a new initiative to lower costs and help physicians, hospitals, and other healthcare providers better coordinate care. The new Center for Medicare and Medicaid Innovation created by the Affordable Care Act launched the Bundled Payments for Care Improvement Initiative. The innovation center is tasked with finding new and better ways to provide and pay for healthcare to a growing population of Medicare and Medicaid beneficiaries.
The current Medicare system pays physicians, hospitals, and other providers that are part of the healthcare delivery team separately for services they provide, including services provided during an episode of care. For purposes of the new initiative, an episode of care might include a single hospital stay (e.g., for a heart bypass or hip replacement) and/or recovery from that stay. Under the bundled payments initiative, CMS will bundle payments for services delivered by healthcare team members during an episode of care rather than paying each provider separately.
CMS says bundling payments across providers for multiple services will give providers greater incentive to coordinate and ensure continuity of care across settings, resulting in better care for patients. Better coordinated care is likely to reduce unnecessary duplication of services and prevent medical errors, thereby improving the quality of care, while lowering costs.
The expected benefits of the bundled payments initiative are not based on supposition, but on the research and experience of leading healthcare institutions nationwide that participated in similar initiatives and demonstration projects. CMS cited one example in which a Medicare heart bypass surgery bundled payment demonstration saved $42.3 million, approximately 10% of expected costs, and saved patients $7.9 million in coinsurance while improving care and lowering hospital mortality.
In response to industry concerns, this new initiative emphasizes flexibility. In its request for applications, the innovation center described four broad approaches to bundled payments. This will give providers flexibility in determining which episodes of care and which services to bundle, facilitating participation by providers of varying size and readiness.
Organizations may apply to participate to the bundled payments initiative by submitting letters of intent no later than September 22 for Model 1 and November 4 for Models 2, 3, and 4.
A change in perspective may help build better physician relationships
Editor’s Note: Linda Renee Brown, a clinical documentation specialist at Banner Good Samaritan Medical Center in Phoenix, AZ, wrote the following post for the Association for Clinical Documentation Improvement Specialists (ACDIS) Blog. Some case managers may be able to relate to her experience of transitioning from bedside nurse to a new role.
I’m an old (and I do mean OLD) ICU nurse. As a working nurse, my relationships with physicians usually centered on getting them to listen to my assessments: Yes, you need to get out of bed and come see this patient who has stopped breathing! And getting them to do what they should to care for the needs of their patients: Yes, I could really use a new central line for the 17 vasoactive infusions you’ve ordered!
I respect their level of education and their place on the food chain, but each physician operates on an individual plane of competency and personality for which I sometimes had to make adaptations in my approach.
When I worked in ICU, there isn’t much I wouldn’t do for a nice, polite doctor who showed respect to me and the patients. I knew how hard it is to become a doctor, and how really hard it is to become a good doctor, so I used to try to help the physicians by writing out a verbal order and having it ready for his or her signature. I would try to have all the necessary supplies ready ahead of time and if something additional was needed, I’d be the first to run to get whatever else was needed. Nice physicians got to sit in my space to write their progress notes. I even shared my Twizzlers.
Conversely, if you were a mean, crotchety doctor who didn’t show respect to nurses or patients, I wouldn’t be necessarily unkind but I certainly wouldn’t go out of my way to make your day better. I probably wouldn’t have your orders written and ready for your signature, I would show you where the supply closet was rather than get your materials ready for you, and I’d most likely not let you use my spot at the nurses’ station to write your notes. And no, no Twizzlers for you. Ever. Because you have to be a nice person, first and foremost.
In 2008 I left ICU and became a CDI specialist. Nobody knew what that meant, least of all the doctors. They just knew that I left on Friday wearing a white uniform and stethoscope and came to work on Monday in street clothes, pushing a computer on wheels.
When I was no longer running cardiac outputs or sending off specimens for C.difficile, they could no longer comprehend my new role against their earlier vision of who a nurse is and the role nurses play in patient care. I had to create a new identity and that meant redeveloping my existing relationships.
My biggest surprise came from a doctor I’ll call Raquel (since that’s her name). Raquel is a wonderful, hard-working physician who always seems to get the most difficult cases. She works too many hours. She eats standing up to save time. When I was an ICU nurse, I was always happy to have Raquel taking care of my patient, and she seemed just as happy to have me as her patient’s nurse. We got along very well. So I was unprepared for the way our relationship changed when I changed roles. [more]
Keep case management on your patients’ radar
Are you a case manager, social worker, or patient navigator who prefers to stay just below the radar screen, or do the patients whom you manage know you and know what to expect from you?
I’m a consultant who advocates for a better understanding of our roles, and a sister of a medically fragile man who has never met or spoken with the numerous case managers who coordinate his care. Here is a noninclusive list of tips to better promote and brand your role and functions:
- Engage patients and families. Before a registered nurse communicates to a third party, he or she must first engage and assess the patient to understand his or her unique story.
- Introduce yourself, and explain your role and what the patient can expect from you, I told patients that I was their WD-40. Case managers grease the wheels of the patient experience. I also told them that if I did not know an answer to a question, I would find someone who did.
- Create a brochure that describes what you do. Use simple words iand offer a brochure in the languages that reflect the populations you serve. This tool can also help other members of the healthcare team better understand your role.
- Explain how you work with other members of the healthcare team, including social workers.
- Explain how you work with episodic case managers, payer-based case managers, and any other liaison roles creeping into the organization. .
- Give patients your contact information. Giving patients a business card is best, but writing your name and contact information on the whiteboard or providing it in via e-mail is even better.
- Follow up with patients. Case managers can be highly influential with respect to the patient experience. Visit patients just prior to their transition to ensure that all of the dots connected and follow up appointments are arranged. Every patient discharged to home should also receive a follow-up phone call. Some hospital administrators believe that staff nurses should make these calls. I ask you, who better knows the post-acute environment, resources, and patient story than you?
- Be accountable. Follow through on what you say you will or can do. The best case managers I know don’t turn their pagers off at 5 p.m. or when they leave for the day. Remain available or explain who is available when you’re not.
This is not just a leadership issue to address, market, and brand. I believe it begins with each and every one of us. It is time to assertively establish our identity and be recognized for our influence on the patient experience.
Identifying failure essential to learning from it
Editor’s note: Donald A. Butler, RN, CCDS, CDI manager at Pitt County Memorial Hospital in Greenville, NC, wrote the following blog post for the Association of Clinical Documentation Improvement Specialists (ACDIS) blog site. Because many organizations house their clinical documentation programs within case management, I think that sharing this adaptation with Case Management Weekly readers will benefit them..
In March, I started a conversation on CDI Talk entitled “Failed Programs,” hoping at the time that there might be someone willing to divulge a first-hand account of how and why their program “failed” and perhaps how they were able to “save” or “reinvent” it. I was hoping to gather enough information develop an article on the topic for the CDI Journal.
While the title of the discussion generated quite a bit of conversation (there were upwards of 36 responses at the time), no volunteers came forward. Unfortunately (or maybe fortunately), I don’t have any first-hand experiences with a “failed”, nor do I have any personal reflections to share from direct colleagues. Furthermore, the online discussion on CDI Talk helped me realize there is not a clear definition for what might be considered a failed program in the first place.
I understand this is a very sensitive subject. There might be real reluctance to participate in such a discussion depending on an individual’s experiences. Revealing serious struggles might yield erroneous implications about a present program and not some previous or anecdotal one. In my humble opinion, however, recognizing program problems can help us seize a genuine “opportunity for improvement.” (I’m not a fan of that phrase, by the way, thus the quotes. Am I the only one who dislikes it?)
But maybe even better than an individual program finding potential success amidst the rubble of seemingly insurmountable obstacles is the possibility that together we can all learn something from each others’ schools of hard knocks.
So, I request input (100% private and confidential) from anyone who might be willing to share their experiences of a CDI program that has either failed or come close. With some good input from our professional community, I believe there will be enough information to provide an article with some great insights into pitfalls and risks, strategies for success, and methods to rebuild.
The Partnership for Patients brings a community approach to healthcare
The old saying “it takes a village” definitely applies to healthcare today. Maybe the tribal people who used the saying to describe what it takes to raise a child knew more about providing appropriate healthcare than they are given credit for. Peeling back the onion of CMS’ new Partnership for Patients: Improving Care and Lowering Costs reveals a community—a village—coming together to appropriately and efficiently care for the citizens of that community.
The Partnership for Patients aims to create new public and private working relationships that currently don’t exist. This CMS innovation targets high-risk Medicare patients with chronic conditions, organ system failure, and frailty. It aims to:
- Improve the transition of inpatients back into the community
- Improve quality of care
- Reduce readmissions
- Reduce patient harm
- Improve medication reconciliation
- Promote safe medication practices
- Standardize communication and information exchange
- Document savings and report it to Medicare
Through the Partnership, the U.S. Department of Health and Human Services (HHS) will reach out to hospital leaders nationwide as well as physicians, nurses, health plans, and employers to improve care and lower costs. HHS says the program has the potential to save 60,000 lives by eliminating preventable injuries and complications of patient care, while saving up to $35 million in healthcare dollars. This could mean a potential savings of $10 billion for Medicare.
HHS is investing up to $1 billion in federal funding under the Affordable Care Act to make this initiative possible. To date, $500 million of this funding has gone to the Community Based Care Transition Program. An additional $500 million will be allocated to the Center for Medicare and Medicaid Innovation to support new demonstration projects related to reducing hospital-acquired conditions. Funds will be invested in reforms intended to achieve two shared goals:
- Prevent hospital patients from injury or becoming sicker.
- Help patients heal without complication
Read more about Partnership for Patients at the HHS website.
The four R’s build a strong case management team
The following post was written by Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, MBA, senior director of case management services for the Kindred Healthcare Hospital Division in Westminster, CA. It first appeared in the April issue of Case Management Monthly.
The case management workforce is aging, and the next generation of RNs essentially has its choice of professional paths and work sites in which to pursue them. However, the number of case management candidates is dwindling, and recruitment and training costs are rising.
Kindred Healthcare’s long-term acute care (LTAC) hospitals use the four “R’s”—recruit, retain, renew, recognize—to recruit and retain quality case management candidates while renewing each case manager’s commitment to the field by offering education opportunities and recognizing achievements.
Recruit
The August 2010 Case Management Monthly described the partnership between Kindred Healthcare and the Samuel Merritt University’s masters program in nursing case Management (MSN/CM). Since then, three graduates have completed Kindred’s six-month case management mentorship program.
The relationship between the hospital and the university in Oakland, CA, has created a pipeline of highly trained case managers who begin their careers with an organization that supports higher competencies. This year, Kindred will hire additional MSN/CM graduates to participate in the mentorship program.
Retain
Kindred is developing an alliance with American Sentinel University’s MSN/CM online training program to offer a career ladder program to existing Kindred case managers. Career ladders and succession planning strengthen the competencies of current case management employees through enhanced training and opportunities for professional growth.
Facilities can take the pulse of their staff through an annual case manager opinion poll, and monitor external market movement and salary competitiveness through surveys. These surveys promote retention through responsiveness to program design and help the facility stay competitive.
Renew
Kindred also joined the Case Management Society of America’s (CMSA) Career Consortium think tank to develop ideas for earlier access to careers, education, and training. CMSA plans to partner with Kindred West Region in development of a pilot case manager career ladder project using CMSA’s online courses. The courses help improve leadership skills and count toward certification.
By contributing to CMSA and other professional affiliations, Kindred shows potential hires its commitment to their professional growth.
Recognize
Internal and external awareness of each case manager’s success stories and outcomes contributes to the growth of the profession and the public’s awareness of the value of case management. Leaders should seek opportunities to address local organizations and publish success stories in industry journals. Encouraging such publication illustrates management’s recognition of the individual’s efforts and helps case managers recognize their effect on patient care as well.
Improve relationships with postacute facilities
The creation of accountable care organizations (ACO) and global payment pilot projects are among the more often discussed initiative in the Patient Protection and Affordable Care Act.
Hospitals can begin laying the groundwork for ACOs by developing relationships with postacute facilities in their communities. They should discuss quality initiatives and improving transfers now before ACOs and global payments take effect in 2013.
Because case managers, social workers, and discharge planners are typically those who communicate with postacute providers, they are the ideal candidates for fostering relationships. Unfortunately, many case managers already have much on their plate and cannot devote much time to meeting with postacute representatives to establish strategic initiatives. This is why Baystate Health (BH) in Springfield, MA, created a role in 2006 devoted exclusively to postacute relations.
Meet Susana Hall, RN, BSN, MBA, director of postacute care (PAC) relationships at BH. Hall essentially is the operations part of a PAC team, developing the health system’s relationships with postacute care providers in western Massachusetts. She does that in two ways—ensuring that postacute facilities share and participate in BH’s vision of quality and negotiating with facilities regarding acceptance of difficult and hard-to-place patients.
Hall meets with representatives from the region’s postacute facilities in strategic planning sessions. During those sessions, they talk about improving transitions and discuss any quality lapses. Hall also negotiates with postacute providers that may be reluctant to accept difficult patients. For example, she says it is sometimes difficult to place Alzheimer’s patients because they tend to “act out” when arriving at a new facility.
“I can call and say, ‘We need your help. I need to ask if you will work with us on a challenging case. What can we do together to make this happen?’ ” Hall says. “We have strong clinical teams in our regional SNFs, and when we approach a challenging case as a team and focus on what is in the best interest of the patient, we have great outcomes. We all work for the same person—the patient.”
In some cases, Hall has negotiated to have BH support the cost of one-on-one services for Alzheimer’s patients until they settle into the new location. Because she is a director, Hall works predominately with administrators, so she often negotiates with chief operating officers and CEO.
