All Entries in the "Discharge Planning" Category

Promoting efficient use of resources and appropriate hospitalization length of stay to physicians, a different approach

Physicians sometimes acquiesce to family wishes and desires and admit a patient for “social” reasons. On the other hand, a physician may keep a patient in the hospital an extra day because the patient expresses a desire to stay just “one more day.” These unnecessary, avoidable hospital days have a material effect on potential revenue loss for the hospital through denied days or denied hospital stays by third party payers.

A major challenge in motivating physicians to move the patient along the continuum is the disconnect between prudent hospital fiscal management and the practice patterns of physicians. The physician generally receives payment for his evaluation and management services regardless of whether the hospital is paid or denied for the patient care.

However, change is on the horizon. Medicare is currently considering provisions that will promote efficiency in the practice of medicine. Medicare and other third party payers are also committed to transitioning from physician payment based strictly on volume to payment based upon the relationship between quality, costs, and outcome. The efficiency and effectiveness of a physician’s practice of medicine will determine the physician’s financial welfare and business success.

Evidence of this impending change in reimbursement can be found in the General Accountability Office’s (GAO) report entitled “Per Capita Method Can Be Used to Profile Physicians and Provide Feedback on Resource Use.”  This report is a must read. In essence the report concluded that it is feasible to use Medicare claims data to profile physicians on resource use, taking into account patient acuity through risk adjustment methodologies.

The report examined the following:

• The extent to which physicians in selected specialties show stable practice patterns and how beneficiary utilization of services varies by physician resource use level
• The factors to consider in developing feedback reports on physicians’ performance, including per capita resource use
• The extent to which feedback reports may influence physician behavior

The GAO focused on four medical specialties (cardiology, diagnostic radiology, internal medicine, and orthopedic surgery) and chose four metropolitan areas (Miami, Phoenix, Pittsburgh, and Sacramento).

Take this oppurtunity to educate physicians about the possible changes in the reimbursement model

The message is out!

Now is the time for case managers to become familiar with these eventual changes to the healthcare reimbursement model from a physician and a hospital perspective. This reimbursement model transition will not only drive out waste in the practice of medicine. It will also drive and promote a collaborative approach to healthcare delivery by using financial incentives.

Case managers should educate physicians on the need to collaborate with case management to move the patient along the continuum efficiently because physicians will receive reduced reimbursement for excessive resources.

Let the education begin.

Providing care to undocumented immigrants

Without question, providing care to undocumented immigrants is a problem that leaves hospitals with few options. Because patients typically do not qualify for government assistance and cannot afford care, hospitals typically foot the bill for these patients, and sometimes the price can be in the millions.

A recent Healthleaders Media article, by John Commins, reported on one such a case. A partially paralyzed illegal immigrant was treated at a Martin Memorial Medical Center for three years before being transferred to his native Guatemala to continue his care. The hospital estimated the cost of treating the man to be around $1.5 million.

The patient’s family sued the hospital claiming that Martin Memorial illegally repatriated the man to Guatamala—a case they ultimately lost. To read more about the case visit the Healthleaders Media Web site.

In the same article, Mark E. Robitaille, CEO at Martin Memorial, said the issue of providing healthcare to undocumented immigrants remains unresolved on a state and national level, and he’s not optimistic that the issue of providing care to undocumented immigrants will be addressed soon.

“This is an opportunity for leaders at the state and federal levels to find a solution, rather than relying on individual healthcare providers to develop solutions on a case-by-case basis,” he says. “Unfortunately, none of the proposed national healthcare reform bills currently being debated in Washington address the issue of how to adequately provide healthcare for undocumented immigrants in a way that is fair and equitable to everyone involved.”

How does your facility handle undocumented immigrants? What resources are available to help your facility collect payment for these scenarios?

Need more info? Check out Caring for Uninsured and Undocumented Patients (Audio Conference).

The FY 2010 IPPS changes impacting case managers

On July 31, the Centers for Medicare and Medicaid Services (CMS) released the FY 2010 Inpatient Prospective Payment System (IPPS) Final Rule. Hospital payment rates will increase by an average of 2.1%, as opposed to the 0.2% proposed earlier in the year. CMS elected not to implement a 1.9% reduction, referred to as the coding and documentation adjustment. This coding and documentation adjustment accounts for changes in clinical documentation and coding patterns—not real changes in patient acuity.

Implications for case managers

The start of the Medicare Fiscal Year IPPS, which begins each October 1, brings a host of new coding, payment, and other regulatory changes including updated relative weights for the 745 MS-DRGs. Some MS-DRG relative weights increase—others decrease. Relative weights are a proxy for patient acuity. Higher relative weights signify higher acuity, providing for a higher level of reimbursement, while lower relative weights translate into lower acuity with less reimbursement.

In reviewing the Healthcare Financial Management Association’s (HFMA) recent overview of the Final 2010 IPPS Rule, an interesting point was made that certainly impacts hospitals and case managers. [more]

Have you mastered the HINN?

Last week, during the HCPro’s Master the HINN: Integrate Policies and Procedures into Hospital Operations audioconference, a poll question revealed that 87% of the facilities on the call designate case managers as the ones responsible for providing HINNs. Does this statistic ring true in your facility?

If so, please share your challenges, comments, and best practices when it comes to delivering HINNs properly and effectively. For example, how do you and your team identify cases where a HINN is necessary? How to you ensure the patient is notified of his or her liability in a timely manner? How do you educate your staff about which HINN is appropriate for a situation?

Guidance to ‘the most appropriate level of care’

Case managers serve as the patient’s advocate to promote safe, quality care during the patient’s stay in the hospital and after discharge. Sounds like the ideal job, right? For nurses who “live” the role, rather than “do” the job, it truly is. Grace’s story is one that conveys how complex, yet fulfilling living the role can be.

Grace read the physician’s orders for Diane to begin outpatient dialysis upon her return to her nursing home. Grace began looking for a dialysis center that would be close to Diane’s nursing home and had chairs available. However, the center that would accept Diane was quite a distance from the nursing home. If Grace were to receive treatment at the facility, she would need to be transported via ambulance three times each week for treatment. Unfortunately, this circumstance was not unusual, so Grace proceeded with making tentative arrangements.

When Grace entered Diane’s room to discuss her treatment, she saw Diane lying on her side. She was thin, drawn, and severely contracted with tunneling decubiti throughout her body. With the slightest movement, she cried out in pain. However she was alert, oriented and communicative. Throughout Grace’s long career as a case manager, she had symbolically seen Diane far too many times.

Grace approached Diane with a warm smile and a trusting, caring tone of voice. After explaining her reason for being there, Grace began to question Diane in order to determine her mental competency and ability to make decisions. After all, Grace was there to determine what Diane needed and wanted, not just to tell her to do what the physician had ordered. Grace sought Diane’s consent for the treatment plan. She explained the risks, benefits and alternatives of her plan for continuing dialysis as an outpatient. [more]

ER case managers must have special skills

A nurse case manager is a definite asset in the emergency room (ER).  An ER case manager benefits the patients, the staff, and the hospital.  The role is multi-faceted and requires superior skills in:

• Quality
• Education
• Communication
• Customer service
• Negotiation
• Creativity
• Risk management
• Knowledge and understanding of insurance requirements and regulatory mandates

It also requires an ability to interact with patients, families, insurance representatives, and caregivers both in the ER and those who are treating the patients in the out-patient arena.

Visits to the ER may have one of several outcomes. Usually, the patient is treated and discharged home with a plan or the patient is admitted to the hospital. It is here that the ER case manager can be most effective to improve the quality of care and prevent readmissions to the ER.

An ER case manager can ensure that each patient who is discharged from the ER has an appropriate discharge plan that is viable and appropriate to assist the patient in recovering and maintaining their health.  A case manager is an expert in confirming the patient can afford any prescriptions provided , is able to be compliant with recommended follow-up visits with  specialists and can assist the patient in connecting with a primary care physician. The nurse case manager can be instrumental in  working with the patient  and their support system to make sure that they understand and have the interest and ability to be compliant with the discharge instructions.

The case manager can enhance the care provided by a busy ER nurse and physician  by assessing situations and family dynamics, listening to the patient and helping them understand the rationale for various tests and the time needed to interpret results. The case manager can assist the ER nurse with patient education and  providing information necessary to maximize  the patient’s health status.

The case manager can also benefit the hospital by working with both ER physicians and admitting physicians to ensure that all acute care admissions meet medical necessity and are admitted to the appropriate level of care.  The case manager can assist with transfers to alternative levels of care such as skilled nursing or rehab when patients do not meet criteria for acute care but are unsafe to return home.  The case manager can arrange home healthcare, physical  and occupational therapy or other appropriate services to help a patient maintain their independence in the home.

Case managers are an integral part of the ER team to improve the quality of care and help maintain fiscal responsibility for resources both in the ER and on the hospital admitting units. Case managers coordinate care and provide patients will all the tools necessary to improve their quality of life and feel their best within any limits of their illness or disability.

Case study: Avoidable days

The following case study uses InterQual® commercial screening criteria as an example.

InterQual is a set of clinical, criteria-based guidelines that give hospitals suggestions for the most appropriate level of care based on the patient’s medical needs and stability. It is a common language for practitioners that, if used correctly, will help a hospital reduce medically unnecessary acute days, improve the quality of discharges, promote patient safety, and reduce denials from third-party payers.

InterQual’s medical necessity criteria are:

• Severity of Illness (SI): Criteria that consist of objective, clinical indicators of illness, which focus on an individual patient’s clinical presentation rather than diagnosis
• Intensity of Service (IS): Criteria that consist of monitoring and therapeutic services, singularly or in combination, which can only be administered at a specific level of care
  • Stand-alone IS criteria: Criteria that consist of services that should only be provided in an acute care hospital, given that the SI supported an inpatient admission
  • *(Asterisked) IS criteria: Criteria that consist of services that could be provided at a lower level of care based on the type of service or the patient’s stability
• Discharge Screens (DS): Criteria for determining clinical stability and level of care appropriateness

The three criteria patterns are:

1. Does not meet IS and meets DS. This pattern represents patients ready for the next level of care with unnecessary and avoidable days. This is the most common pattern and may represent unnecessary utilization.

2. Meets IS and meets DS. This pattern represents patients who may be ready for a lower level of care, but who are still receiving acute care services. This pattern may represent overutilization.

3. Does not meet IS and does not meet DS. This pattern represents patients who are acutely ill and may not be receiving acute care services necessary for definitive treatment. This pattern may represent underutilization.

For example:

8/07/09 IS cardiac monitor, Lasix 20 mg PO BID, 2LO2/NC*
_____________________________________________________________________
DS NSR (82), RR 20, O2 sat 97% RA, eating 80% of meals, 1.3 kg Ø

On this day (8/07/09), the patient does not meet IS and meets DS. Fortunately, since the case manager was monitoring the patient yesterday, the discharge has been preplanned and everything is ready to go. There will be no potential avoidable day (PAD) assigned to this case.

But what if the attending physician refused to discharge the patient on this day (8/07/09)?

In general, if the DS is met and the discharge is not scheduled or is not included in the immediate plan of care, the case manager must contact the attending physician regarding the discharge plans or justification for continued stay. If the attending physician does not agree with the case manager’s assessment of discharge readiness and cannot justify a continued stay, the case should be referred to the physician advisor (PA). If the PA concurs with the case manager’s findings, the attending physician must be contacted to discuss the case. The PA may approve a continued stay based on medical judgment and not the criteria. The PA should document the outcome of his or her review and rationale for the decision on a PA referral form. If the PA concurs with the case manager, then:

a. A PAD is assigned to the attending physician
b. The case manager and PA follow the hospital and QIO procedure for issuing a Medicare continued stay denial letter, if necessary

This patient (let’s call her Mrs. B) had an LOS of two days. This is a very short LOS, but as you can see from the previous scenario, Mrs. B did not need to stay another day in the hospital. She was stable and safe to go home—and home is a much safer place than a hospital.

Editor’s note: This case study was adapted from The Avoidable Day Analyzer: Data Identification Tools for Effective Case Management, Second edition.Order your copy today online at HCMarketplace.

Safe discharge plans for the uninsured

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?