All Entries Tagged With: "avoidable days"

Improve PASRR processes to prepare for healthcare reform

Before discharge planners refer patients (regardless of payer source) to a Medicaid-certified nursing facility, they must screen them for serious mental illness (SMI) or mental retardation (MR).

Preadmission Screening and Resident Review (PASRR) is a federal mandate that protects individuals with SMI or MR from placement in facilities that can’t provide their specialized level of care.

The PASRR program uses two levels to screen patients for these conditions.

All prospective nursing facility residents must undergo a Level I screen. “The Level I screener makes judgments about the adequacy of existing information to rule out SMI or MR,” according to CMS’ website.

Level I screeners can’t make or verify diagnoses. Discharge planners typically perform these screens by completing a form using information contained in the medical record. They can’t draw conclusions beyond the following:

• Documented evidence is sufficient to rule out SMI/MR; individual can be admitted into the nursing facility.
• SMI/MR can’t be ruled out, and thus a Level II Individualized Evaluation is required.
• Documented information is sufficient to apply certain predetermined criteria and make a categorical determination.

A Level I screen typically takes 24 hours, according to a 2006 report by the Substance Abuse and Mental Health Services Administration (SAMHSA).

The Level II screen is more complex, and therefore more time consuming. The SAMHSA report estimates that a Level II screen can take seven to nine days. Because patients remain in the hospital for a Level II screen, this process can significantly increase a patient’s LOS.

Jackie Birmingham discussed PASRRs in “An Overlooked Element of Health-Care Reform: PASRRs” published recently in the Curaspan Connections newsletter. Because healthcare reform will increase the number of nursing facility referrals, Birmingham suggests hospitals improve their processes to screen patients quickly.

“With more patients qualifying for nursing home coverage and therefore more Level I screening, there will be more Level II screening as well. You can therefore expect longer lengths of stay for more patients unless a plan is in place to screen, process and document cases in a timely manner. If you anticipate that a patient will need a nursing home, you’d better clear Level I quickly,” Birmingham writes.

AHA affiliate publishes a readmissions guide

Government agencies and payers are paying closer attention to reducing the number of preventable readmissions and for good reason. A recent study published in the New England Journal of Medicine concluded that preventable readmissions cost the Medicare program $17.4 billion in 2004.

To help hospitals curb the number of preventable readmissions, the Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association (AHA), created a guide to “assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.”

The “Health Care Leader Action Guide to Reduce Avoidable Readmissions” includes four steps:

• Examine your hospital’s current rate of readmissions.
• Assess and prioritize your improvement opportunities.
• Develop an action plan of strategies to implement.
• Monitor your hospital’s progress.

Step three is particularly interesting. It lists several readmissions strategies that facilities use during hospitalization, at discharge, and after discharge. Each strategy has a “level of effort” designation—high, medium, or low—based on necessary resources. The guide also encourages collaboration by identifying facilities that have implemented similar strategies.

Preventing unnecessary readmissions requires a community approach, and many of the factors that contribute to preventable readmissions occur outside the hospital, according to HERT. However hospitals must also do their part or risk financial penalties proposed in recent legislation.

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.

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.