All Entries Tagged With: "admission case management"
Communication between physicians and case managers reduces patient risk
Case managers continue to struggle with maintaining a balance between doing what is right for the patient and ensuring that their facilities receive proper reimbursement. RAC auditors or a third-party payer may not agree with their patient status decisions, which means their healthcare organization will end up providing free healthcare.
Software programs such as The Milliman Care Guidelines®and InterQual® Criteria, as well as Medicare regulations, help case managers and physicians determine the correct patient status, the appropriateness of continued stays, and appropriate discharges. These tools are only part of what is necessary for the decision-making process.
The key to determining appropriate patient status is considering patients’ physical condition and clinical picture. Remember that patients are either inpatient or outpatient; observation is a service not a status. Ongoing communication and collaboration between physicians, nurses, and case managers is essential to putting all the pieces together to do what is right for patients.
Communication can be difficult as physicians find their time stretched very thin between clinic care and hospital care. Case managers must understand this, but physicians must also understand that assigning appropriate and timely admission status is important. Physicians must give orders in a timely manner to avoid delays in care, which increase LOS and put patients at risk.
Case managers and physicians must come together with a plan to provide appropriate admission status and care in a timely manner. There is no one or two sentence solution to this. It takes is open communication between the two positions. Building a strong relationship between case managers and physicians will reduce the number of patients that are at risk. If we, as a healthcare team, do what is truly right for the patient, everything else should fall into place.
How is the communication between case management and physicians at your organization?
Providers ask CMS to abolish observation services
Several providers suggested CMS abolish observation services during a CMS listening session titled, “Medicare beneficiaries receiving extended observation care as a hospital outpatient” August 24.
The session began with statements from Jonathan Blum, Deputy Administrator and Director, Center for Medicare Management. He said the purpose of the listening session was to understand the increase in extended observation stays and whether CMS needs to change its guidance or regulations or to provide better education for beneficiaries, or both.
The observation problem defined
According to Chapter 4 of the Medicare Claims Processing Manual, CMS defines observation services as:
“specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.”
However, many of the comments made during the August 24 call indicated that facilities do not use observation services in that manner.
Pressure from government auditors (such as the recovery audit contractors) has forced facilities to use observation services as a “safety net” level of care. In many cases, extended observation patients are too sick to go home but nevertheless do not meet admission criteria, callers stated. Although physicians feel the patients require hospital care, facilities expect Medicare will deny the payment.
Several callers expressed frustration with the fact that inpatient admissions hinge on admission software products such as InterQual and Milliman. A medical director of care management in Florida said these admission criteria products use arbitrary definitions that are often vague and difficult to understand. He also stated that the difference between inpatient and outpatient can sometimes be “two or three points in their sodium level.”
Although a physician’s medical judgment trumps admission criteria, a caller from Maryland stated it is often difficult to obtain documentation that supports a physician’s medical decision making.
The solution?
Commenters agreed that the observation issue is confusing, and one of the more popular suggestions was for CMS to eliminate of observation services altogether.
One caller presented Oregon Health Plan’s (OHP) policy as an alternative. OHP does not ask hospitals to make level of care determinations. Instead, OHP pays hospitals for outpatient services if patient is in the hospital less than 24 hours and pays inpatient rates for any stay that exceeds 24 hours.
Other commenters pointed out that, eliminating of observation services could lead to more complications such as emergency department overcrowding and complications with qualifying for a Medicare covered SNF stay.
Do you think observation services should be eliminated?
Look for more information in the November issue of Case Management Monthly
RACs continue to add DRGs to target lists
I don’t know about you, but I am worried about the ever growing number of DRGs added to the Recovery Audit Contractors’ (RACs) target lists.
One RAC plans to audit more than 75% of all DRGs that hospitals in their jurisdictions submit. Initially I was puzzled. Why so many issues with the DRGs? The coders do a good job. They use software. What is the problem?
Yesterday, the proverbial light bulb went on for me. It’s not the coders fault. I would like to share the anecdote that got me thinking.
In the late 1990s, a health plan quality improvement nurse colleague asked me to help design a disease management program with a major pharmaceutical company. The intent of the program was to improve outcomes for their many diabetic and congestive heart failure (CHF) members.
We needed to identify about 500 potential candidates for the program. My colleague had her IT folks identify 1,000 members whose claims included diagnoses for diabetes and/or CHF. We pulled 1,000 charts knowing that some would not meet criteria, but we were confident we would find more eligible patients than we needed.
We reviewed 1,000 outpatient clinical records to determine each patient’s eligibility for the program. Those of us who reviewed the records audited the provider’s outpatient record against a clinical data set provided by my quality improvement colleague. The idea was to validate the diagnosis on the claim against the patient’s actual condition. No big deal. I thought.
To substantiate systolic CHF we looked for an ejection fraction below 50, weight fluctuations, positive chest x-ray, use of diuretics, etc. For diabetics were looked at the HBA1C values, medications, presence or absence of complications, etc.
I was surprised that two-thirds of the CHF charts we reviewed did not contain documentation to support the diagnosis when compared to clinical criteria. In fact, many CHF patients had ejection fractions well above normal. We were barely able to identify 300 cases with clinical documentation and lab/radiology results that supported the coded diagnosis. In my opinion, the coders were not at fault because they worked with the diagnoses recorded in the chart.
Diabetes was not as problematic, but we did see many errors in diagnosis assignment based on lab results and lack of documented complications.
The case management and utilization review team I worked with focused on commercial admissions because we were short-handed. Commercial payers typically require clinical review within 24 hours of admission or else they will deny the day.
We knew CMS would reimburse something for the Medicare admission because of the DRG payment system. Since there was no need to call in clinical information for Medicare patients (unless they were managed Medicare) most Medicare admissions were overlooked until discharge planning. Not ideal, but we did the best we could.
Do you think the RAC auditors are discovering the same or similar issues with DRG assignment? How many case managers are actively working Medicare admissions?
What problems do you think the RACs are finding with the DRG assignment that are causing the scrutiny now?
Download an admission/readmission assessment form
Karen Zander RN, MS, CMAC, FAAN principal and co-owner of The Center for Case Management in Wellesley, MA was kind enough to share an admission/readmission assessment form in the March issue of Case Management Monthly.
The form is designed to help assess a patient’s risks, barriers to discharge, and potential for readmission.
Download the full admission assessment form, with the readmissions addendum, here.
Length of stay should not be a secret
Hospital organizations need to realize and act upon the fact that discharge planning begins at the time of admission. In 2007, MedPac (Medicare Payment Advisory Committee) told Congress that readmissions cost the government $15 billion a year (MedPac, 2007). Since then, there has been a strong emphasis placed on readmissions.
Estimating a patient's LOS at the time of admission helps establish how much time you have to complete the discharge plan
One of the first things we need to explain to patients and/or families is the patient’s expected length of stay (LOS). For the most part, patients want to come to the hospital, get treatment, and return to their prehospitalization setting. This is done through an interdisciplinary approach, which includes healthcare providers, the patient, and family members. In preparation for appropriate and thorough discharge planning, everyone needs to know how many days they have to complete the discharge planning.
Each hospital should track the Geometric LOS provided by Medicare, which can be used as a reference tool. Let’s say, for example, you admit a patient with chronic obstructive pulmonary disease (COPD) and the average LOS is 3.2 days. You can use this information to establish the amount of time the healthcare team has to implement an effective and successful discharge plan. Patients must be part of this plan and need to know what the average LOS is; however, patients must understand that each stay is individualized and their physician will ultimately determine their appropriate discharge time.
Our hospital gives a discharge flyer to patients upon admission. This flyer tells patients what they can expect in regards to discharge planning and their LOS. The flyer allows the patient and healthcare team to set mutually agreed upon goals. It also ensures patients feel confident about their healthcare at discharge. Since our hospital has a seven-day case management model, our admission case managers provide the flyer and the estimated LOS to our patients. They also discuss the LOS with the other members of the healthcare team so they can initiate the appropriate discharge planning.
Does your organization keep the patient’s expected LOS a secret or does it share LOS with the healthcare team, patient, and family?
Reference: Medicare Payment Advisory Commission (MediPac), 2007. Report to Congress: Promoting Greater Efficiency in Medicare. Payment Policy for Inpatient Readmissions. June, 2007.
Sample transfer agreement
The January issue of Case Management Monthly includes an article about the importance of reciprocal transfer agreements.
Sherri Sochaski RN, BAS, director of case management at JFK Medical Center (JFKMC) in Edison, NJ was kind enough to provide a sample transfer agreement form from her facility. It is good parctice for facilities like (JFKMC), who accept patients for a more advanced level of care, to have a reciprocal transfer agreement policy. Reciprocal transfer agreements ensure the accepting facility can return a patient after specialized care is no longer necessary.
Identifying emergency department regulars can improve throughput
It would be safe to say that every emergency department (ED) sees a fair share of “frequent fliers” or those patients who seem to use the ED as an alternative to other healthcare resources in the community. Knowing “the players” or the clientele of the ED can help an ED case manager address issues that affect throughput.
In the past year, we at University Hospital, Upstate Medical Center in Syracuse, NY have put together a pilot program, patterned after programs we have seen in other hospitals. The hospital generated a list of frequent fliers in the ED during the previous six month period. We identified a group of patients who not only frequent the ED but also have primary care providers within the same hospital system. We used a team approach involving case managers and social workers in the outpatient setting, to address any barriers in the patients’ lives that may cause him to use the emergency department rather than the primary care office.
The expectation was that a social worker or case manager would see the patient each time one of theses patients presented to the ED or the outpatient setting. The social worker would document the reasons for the visit as well as any interventions in a shared file in the computer. We were all able to access that information daily, and keep tabs on the progress of each patient.
The goal is not to keep patients from emergency care. Sometimes those patients presented to the ED with legitimate emergencies, but often times a different setting would have been more appropriate. In the first six months we were able to decrease the number of ED visits in all the identified patients, and we saw an increase in the number of attended visits with their primary care providers. When the hospital generated list of frequent fliers in the next six month period, over half of the original patients were no longer on the list.
I believe that the ED case manager is a crucial part of the throughput process, and knowing the clientele can only enhance the productivity and efficiency in the ED.
Critical care tutorials
I came across this excellent reference for critical care that case managers may wish to use in their review of cases as part of the admission to Intensive Care Units. While screening criteria provides guidance from an intensity of service and severity of illness standpoint as to clinical conditions warranted admission and continued stay in the ICU, there are instances where patients do not meet the ICU criteria as published, yet from a clinical perspective the patient appears to be “sick” enough to appropriately be admitted and managed within the confines of the ICU.
In an earlier post, I discussed the merits and importance of physician clinical documentation to support his/her clinical impression and reflection of medical decision-making and clinical judgment. With this in mind, one may find the critical care tutorials helpful in expanding one’s knowledgebase and clinical understanding of critical care from a physician’s perspective. The tutorial includes definitions of critical care including a discussion on the different clinical entities constituting critical care. A quick review of these tutorials will help in gaining a better appreciation for critical care, thereby assisting the case manager in recognizing possible physician clinical documentation deficiencies contributing to inaccurate reflection and reporting of patient acuity, patient acuity required to clinically substantiate admission to the ICU. To this end, the case manager can address the identified documentation deficiencies with a clinical discussion with the physician.
The critical care tutorials can be found here.
Enjoy
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.
