All Entries in the "Discharge Planning" Category
Sneak Peek: Barrier reduction teams improve efficiency at New York-Presbyterian
If your facility has factors that slow down the patient discharge process, your frontline staff members likely have a good idea of the problems. However, frontline staff at most facilities do not have the means to communicate the problems or help make improvements.
At New York-Presbyterian Hospital in New York City, this is no longer the case.
Leaders there established multidisciplinary barrier reduction teams (BRT) in late 2009, which are designed to increase efficiency and improve communication at the organization. The teams give staff members a way to speak up about issues that may hinder patient care and the discharge process.
This article is adapted from an article which originally appeared in the May Case Management Monthly published by HCPro, Inc.
Ability to pay drives hospital length of stay
Uninsured patients spend less time in the hospital than insured patients, according to a study that suggests that ability to pay plays a greater role than medical need when determining length of stay.
“The only two explanations we could come up with are either people without insurance are being discharged prematurely or hospitals are keeping people who can pay longer to increase revenue,” Arch G. Mainous, III, the author of the study, told HealthLeaders Media.
The study, published in the December issue of Annals of Family Medicine, examined nearly 850,000 adult discharges between 2003 and 2007, at for-profit, non-profit, and government hospitals nationwide. The findings show that in hospitalizations for ambulatory care-sensitive conditions – which should have been avoidable through disease management and preventive care — uninsured patients stayed an average of 2.8 days.
Privately insured patients stayed an average of 2.9 days, and Medicaid patients averaged 3.2 days. For patients hospitalized with non-ACSCs, the average length of stay averaged 2.7 days for the uninsured, compared with 2.8 days for the privately insured, and 3.1 days for Medicaid patients.
“We have relatively robust findings that appear over and over that people without insurance, regardless of what they come in for, stay a shorter period of time, even on things where they might be sicker,” says Mainous, a researcher with the Department of Family Medicine at the Medical University of South Carolina, in Charleston.
“We controlled for how sick they were. We controlled for people who left the hospital early against medical advice. It still shows up,” he says.
The study found that in-hospital mortality for uninsured patients with non-ACSCs was higher than at both nonprofit and for-profit hospitals, while there was little difference in mortality among patients hospitalized for ACSCs.
Mainous says the findings “are not completely surprising but very distressing.”
“Healthcare businesses providing uncompensated care would be like providing uncompensated hamburgers at McDonald’s. There is only so much you can do in terms of supplying free stuff,” he says. “As we see the proportion of people without insurance continuing to rise, it is a wake-up call. Are we going to have a two-tiered system where there is going to be a small proportion of people who get a level of care and others who don’t?”
Mainous says the study isn’t about a chasm between rich and poor so much as it is about the insured and the uninsured. “If you look at the Medicaid group, they did actually well,” he says. “Those folks seem to stay in as long as the privately insured, or ever longer. The cut point for access to care is insurance.”
Mainous says he hopes the study will help policymakers as they try to determine how this nation will pay for healthcare. “We are probably going to move more and more away from employer-based health insurance. As we do that and more people become uninsured it is going to be a big issue. If you go from 46 million without insurance to 100 million people without insurance I don’t think it is sustainable,” he says.
“This boils down to the final ethical issue: Do we consider healthcare a business? That is the take home question. If you consider it a business then you let in people who can pay your fees and you try to make money,” he says. “If you don’t consider it a business, then we need to look at it in a different way.”
8 reasons why hospitals should reduce bed volume
By Cheryl Clark, for HealthLeaders Media
There are nearly one million hospital beds in the United States. But I’ve been wondering, what are we going to do with all the empty ones if the healthcare industry successfully achieves the goals of reform?
Should hospitals start thinking about closing them down? That’s anathema to the premise under which the industry has functioned for decades, which holds that the number of services, buildings and patients must grow to stay in play and maintain respect in the community.
Before you ask what I’ve been smoking, (nothing!) hear me out:
1. One in five or six patients is now readmitted within 30 days, but penalties and incentive programs can dramatically prevent those readmissions. A one-third reduction is not an unreasonable achievement, Elliott Fisher, MD, director of the Dartmouth Institute’s Center for Population Health, told me last week.
Fisher lamented how hospitals that have successfully reduced readmissions have turned around and launched questionable service lines that don’t improve care, such as spine surgeries. Hospitals are expanding volumes for procedures that, given correct and balanced information about their effectiveness and their alternatives, he says, patients would choose not to have.
“With hospitals that are dependent on fees for maintaining hospital margins, reducing unnecessary readmissions and avoidable admissions causes revenue losses, which will lead them to admit other patients to the hospital” for these elective procedures, he said.
That’s not consistent with the “systematic reform in healthcare that we at Dartmouth have been calling for, (which) is about keeping people healthy so they don’t need to be in the hospital,” he continued.
“It’s about making sure patients make informed choices about major surgical procedures or elective procedures, and then right-sizing the healthcare system, which may very well lead to many, many fewer hospital beds and hospitals in this country. And that’s how you would get lower costs.”
2. More patients will be encouraged – perhaps through premium incentives – to sign advance directives. We know from research that treatment-limiting advance directives have the potential to prevent aggressive, expensive, but futile care at the end of life, especially in regions of the country where imminent death is more expensively and often painfully prolonged.
3. Doctors and nurses will get better at constraining healthcare-associated infections, thus reducing longer stays. They will get better at preventing falls, surgical mishaps, and other avoidable adverse events, in part because those will now be publicly reported and because that extra care those errors require will not be federally reimbursed.
4. More patients will be treated in outpatient settings, because accountable care organizations and coordinated outpatient services will make sure patients stay out of the hospital if they don’t need to be there. Patients who do need hospital care will be discharged earlier because bundled payments will hasten that process.
Just this week for example, we see a report that many elective percutaneous coronary revascularization patients can be safely discharged six hours after their procedure, rather than kept in a hospital bed overnight. This could free at least 35,000 or more hospital beds days each year.
Even bariatric surgery, which just a few years ago required a hospital stay of a week or more, is now being done laparoscopically. Adjustable gastric band procedures, approved by the U.S. Food and Drug Administration in February, can sometimes be done on an outpatient basis.
5. Emergency departments will become even more creative in managing patients who don’t need admission, using urgent care clinics and observation alternatives.
6. In some states the number of hospital beds, even with hospital closures, is on the increase. In California, for example, the number of hospital beds has had a net growth of 5% between 2005 and 2010, according to the Office of Statewide Health Planning and Development. And, many hospitals that are rebuilding to meet the state’s strict safety requirements are adding licensed beds, not reducing them, as they upgrade from double-bed rooms to single-bed rooms, and expand in an effort to dominate a market.
Now, I know what you’re thinking: “What about all the normal growth in population and all the aging baby boomers who will soon need care? What about the 32 million uninsured Americans who will soon have coverage?”
7. Yes, aging baby boomers will need acute care. But how much? This generation isn’t the type to be content lying around in hospital beds at the rates of prior generations. They will do more research about their conditions and question medical authority more. And they will be better managed outside hospitals.
Last week, a survey in the Archives of Internal Medicine, found that 42%of primary care doctors “believe that patients in their own practice are receiving too much care,” that is, too many referrals and too many tests, and only 6% said patients are receiving too little. About 28% said they are practicing more aggressively than they would like.
8. As for those 32 million people who lack health coverage. Remember, most of them are barely accessing the healthcare system now. And if they are, it’s an inefficient and more expensive service, they’re getting at best. And in theory, much of it will be avoided with earlier, more preventive care.
Besides, I don’t believe that healthcare reform will prompt them to charge into hospitals to make up for lost time. Coverage should help them stay healthier.
You might argue that hospitals should keep those beds and even expand capacity to be ready in the event of an epidemic or disaster. Good point.
But remember that in the wake of the 9/11 attacks and the threat of H1N1, pandemic planners have been busy preparing to adapt schools, theaters, and even cruise ships to handle casualties outside of hospitals. During a crisis, a hospital may not even be the safest place to go.
These decisions are certain to further drive down rates of reimbursement for hospitals, physicians and other providers. And who knows how they will choose to compensate for that, whether by reducing services, salaries and staff, merging forces, postponing construction projects and by just being logarithmically more efficient than they are today.
Or by contriving ways to market more services with hefty margins, whether justified or not.
As Fisher said, the problem is not just readmissions, “it’s avoidable admissions overall.”
Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached at cclark@healthleadersmedia.com. Follow Cheryl Clark on Twitter.
Readmission reduction pilot program saves hospital thousands
A recent article in The Miami Herald describes a readmission reduction pilot program at Jackson Memorial Hospital that saved it an estimated $400,000 in readmission charges.
Jackson nurses visit recently discharged heart patients at their homes to ensure that they’ve filled their prescriptions and understand medication instructions. The nurses also leave frozen healthy meals and check in with patients regularly to monitor their conditions and provide more meals.
The article describes Jackson’s pilot program as a predecessor to accountable care organizations (ACO). The ACO model is widely praised, but this article explains the need to address several challenges. Antitrust and anti-kickback healthcare laws require revisions that will allow healthcare providers to refer patients to entities with which they have a financial relationship. However, some groups warn that relaxing antitrust laws could allow healthcare providers to create the monopolies that these laws were enacted to prevent.
Editor’s note: Read the article at http://www.miamiherald.com/2011/08/03/2344316/will-acos-create-a-revolution.html
CMS proposal would eliminate homebound requirement for Medicaid beneficiaries
A recently proposed rule (CMS 2348-P) would change the definition of homebound for the purposes of determining eligibility for Medicaid-covered home health services.
Homebound status, along with medical necessity and a physician’s plan of care, is one of three basic requirements for eligibility of homehealthcare, Jackie Birmingham, RN, MS writes in Curaspan Connections. Birmingham, explains that case managers typically screen for homebound status first when assessing patients for levels of post-acute services.
CMS considers patients homebound if they leave home infrequently, for short periods of time, or for medical treatment. Patients must meet the homebound requirement to qualify for Medicare-covered home health services, but the proposed rule would eliminate homebound status as a requirement to qualify for Medicaid-covered home healthcare.
The rule also proposes eliminating the restriction that home health services must be provided in a patient’s home.
Birmingham notes that expanding home health services to include those administered outside the home blurs the line between home care and community care. This makes a case manager’s job more difficult, she says.
A sharper distinction between home care and community care will facilitate application of that care. A community-based benefit can be provided within the existing infrastructure of home healthcare, but it requires more complex administration by case managers and more active involvement by recipients, she explains.
Services for a specific beneficiary may require scheduling at more than one location. For example, recipients scheduled to receive nursing visits at their place of employment who are then unable to work that day won’t be in the right place at the right time.
CMSseeks public comment on the proposed rule. Submit comments at www.regulations.gov/#!documentDetail;D=CMS-2011-0133-0002. The deadline for comments is September 12, 2011.
Will readmission reduction hurt your hospital’s bottom line?
The Hospital Readmission Reduction Program (HRRP) will reduce reimbursement to hospitals with high readmission rates to encourage them to prevent patients from returning after discharge. However, a new study suggests that hospitals will see an even bigger reduction in reimbursement if they experience fewer readmissions.
The issue is simple math. The current system pays hospitals for episodes of care. If hospitals reduce their readmissions they will have fewer episodes to bill. Fewer bills mean less reimbursement.
Brett Stauffer, MD, and colleagues, is the author of an Archives of Internal Medicine report, which examines the financial impact of reducing heart failure readmissions at a community hospital in Garland, TX. Although the hospital reduced preventable heart failure readmissions by 48%, it also lost an average of $751 for each heart failure patient. The authors estimated that the HRRP will reduce the hospital’s negative financial impact, but by only 10%.
The study raises an interesting question. Although reducing hospital readmissions will save money for Medicare and other payers, what does it mean for hospitals?
“While we are not-for-profit entities, at the end of the day we still have to make payroll,” Stauffer told HealthLeaders Media. “We have bills to pay and have to maintain enough margin to pay for capital expenses, build new facilities and keep them updated, and that’s got to be paid for by somebody,” he said.
The hospital, which does not admit a large number of CHF patients, will continue its efforts to reduce readmissions because it is the right thing to do, said Stauffer. Other hospitals may share this perspective. The report seems to suggest that providing hospitals an incentive might require moving away from a pay-per-episode model and rewarding hospitals for positive outcomes. The Value-Based Purchasing program final rule may prove to be a step in that direction. Stay tuned.
Readmissions reduction program beginning to take shape
CMS has begun to lay the foundation for the coming hospital readmission reduction program as part of the inpatient prospective payment system (IPPS) proposed rule posted April 19.
The program, which was mandated by The Patient Protection and Affordable Care Act (PPACA), will reduce Medicare payments to hospitals that have high readmission rates.
Within the IPPS proposed rule, CMS adopted the National Quality Forum (NQF) definition of readmission:
…as occurring when a patient is discharged from the applicable hospital to a non-acute setting (for example, home health, skilled nursing, rehabilitation or home) and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization.
CMS specified the readmission time frame is 30 days; however, there are exclusions for readmissions unrelated to the original diagnosis, as specified by the HQF, Kimberly Anderwood Hoy, director of Medicare and compliance at HCPro, said in a recent blog.
CMS will reduce payments using an adjustment factor that will apply to a particular hospital’s DRG base amount. The adjustment factor can be no more than 1% in FY2013, the first year of the program, and will be phased in until the full adjustment factor of 3% is reached in FY2015. In FY2013, CMS will apply the adjustment factor to the excess readmission ratio for the following applicable conditions: myocardial infarction, heart failure, and pneumonia.
However the number of applicable conditions may increase in the coming years. Gloryanne Bryant, RHIA, CCS, CCDS, suggests in a recent HCPro article that hospitals prepare for the program by identifying their top readmission conditions. Bryant is regional managing director of HIM, NCAL Revenue Cycle, at Kaiser Foundation Health Plan, Inc., & Hospital in Oakland, CA.
“I would recommend that hospitals run some data to look at readmission rates to determine what their top three to five readmissions conditions are,” she says. “It’s clear that readmissions are a topic of concern for the federal government. Even though we in the industry have talked about readmissions for years, this federal mandate means we need to look at it even more closely.”
Face-to-face requirement
Please take a moment to let us know how the face-to-face encounter requirement has affected your organization. Please feel free to elaborate on any challenges you have encountered in the comments section below.
Home health face-to-face requirement effective April 1
The home healthcare face-to-face requirement will go into effect as scheduled.
CMS Director Jonathan Blum told the Face-to-Face Workgroup that CMS expects full compliance with the home health face-to-face requirement starting April 1.
The requirement mandates that any patient referred to a home health agency must have a face-to-face encounter with a physician or other licensed independent practitioner (e.g., nurse practitioner, certified nurse midwife, or physician assistant). Failure to comply will result in a payment denial.
The Face-to-Face Workgroup, which is made up of representatives from ACMA and a number of other organizations, has been actively working to share with CMS their concerns regarding the face-to-face requirement.
Linda Sallee, RN, MS, CMAC, IQCI, member of the ACMA National Board of Directors, met with CMS Administrators in Washington, DC to discuss case management’s concerns related to the home health face-to-face requirement March 18.
ACMA also detailed its concerns in a March 17 letter to CMS, which is available on the ACMA website. The letter included three requests, one of which asked CMS to delay the implementation of the requirement. Others included the development of a standardized tool for documenting that the face-to-face encounter occurred and that CMS would conduct educational efforts for providers.
Read the CMS email that states the agency expects full compliance with the requirement.
Read more about ACMA’s public policy efforts at the ACMA website.
ACMA meets with CMS to discuss face-to-face requirement concerns
The ACMA public policy committee presented its concerns about the new face-to-face requirement to CMS, and expects a response from the agency next week.
The face-to-face requirement mandates that any patient referred to a home health agency must have a face-to-face encounter with a physician or other licensed independent practitioner (e.g., nurse practitioner, certified nurse midwife, or physician assistant). Failure to comply will result in a denial of payment. Penalties for noncompliance become effective April 1, 2011.
Linda Sallee, RN, MS, CMAC, IQCI, a member of the ACMA National Board of Directors, represented ACMA during a multi-organization meeting on the face-to-face issue. Other organizations represented at the meeting included American Association of Retired Persons, American Hospital Association, AMA, American Medical Directors Association, Center for Medicare Advocacy, National Association for Home Care and Hospice, Society of Hospital Medicine and the Visiting Nurse Associations of America.
ACMA compiled a list of the major issues affecting case managers after receiving member feedback and discussions by its public policy committee. The issues include:
- Lack of standardization
- Redundancies for case managers
- Difficulty discharging to rural areas
- Burden on physicians/physician compliance
- Confusion among practitioners
ACMA detailed each of its concerns in a March 17 letter to CMS. Read the letter here.
Read more about ACMA’s efforts regarding the face-to-face requirement issue at the ACMA website.
