All Entries Tagged With: "communication"
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]
Communicating with physicians is the key to effective case management
In my last blog post, I focused on key clinical documentation provisions that help physicians demonstrate medical necessity for the admission.
Allow me to share a recent experience I had with a physician group regarding clinical documentation, which demonstrates the value in engaging physicians in a dialogue about the merits of clinical documentation.
Two months ago, I met with a group of hospital case managers. During that meeting, we discussed working with physicians to establish medical necessity for inpatient admission and continued stay. I asked the case managers their process for communicating with physicians when a patient does not meet screening criteria for a hospital admission or a continued stay. The resounding answer from the group was that the case manager leaves a note for the physician asking him or her to document medical necessity, order observation services, or discharge the patient.
The next day I met with the hospital’s cardiologist group to discus documentation shortfalls I recognized after reviewing their inpatient records. I asked how they typically respond to the case managers’ notes. They answered that they generally ignore the notes because they do not know what constitutes medical necessity. They said if they knew what accounts for medical necessity they would be sure to include the elements in the documentation.
I shared this information with the case manager group. I told them the cardiologists would be willing participants in the documentation process if given the opportunity to learn what constitutes medical necessity. This was a revelation to the case managers. They assumed the physicians knew what constituted medical necessity. [more]
Think of case management as a proactive team
The nuts and bolts of case management operations involve a collection of disciplines with whom case managers work closely while managing their individual assignments. Nurses, physical therapists, dieticians, pharmacists, respiratory therapists, wound care specialists, and dialysis nurses aid in the planning of a patient’s smooth and effective transition to the next level of care.
Early rounding with treatment team members helps identify roadblocks that prevent the transition of patients to other levels of care or to home. Their input may provide information that may not be documented yet. This is helpful because delayed documentation can delay discharges if a case manager receives important information late in the process. This collaborative approach also promotes team bounding and fosters an appreciation of the efforts everyone puts forth in the treatment of patients.
Once case managers identify the discharge destination, they must communicate with the primary care nurse. Early support from the primary care nurse can mean a two to three-hour discharge rather than a five to six-hour discharge. These hours are valuable to case managers who work on multiple discharges simultaneously. When communicating with the primary care nurse, describe the information and actions required to create an effective and timely discharge plan for the patient.
The intensive care unit’s (ICU) goal is to discharge patients to the next appropriate level of care within two to three hours of receiving a discharge order; the norm is two hours and it has become the expectation. Considering all obstacles, meeting that expectation is truly a proactive team effort. Direct involvement of the ICU director, the unit manager, and the charge nurse keeps the revolving door moving. The team meets throughout the day to discuss discharges and transitioning patients out of the ICU.
Discharges will always occur, but assessing patients for discharge needs and communicating with the physician team will determine how soon it may happen.
Decrease length of stay through communication and collaboration
The case management team’s objective is to come up with a safe, agreed upon discharge plan for the patient and develop goals to reach that discharge plan in a timely manner and cost effective manner. The only way to accomplish that objective is through proactive, ongoing communication within the team.
At the healthcare facility where I am the director of case management, we have a -team of highly-skilled, experienced social workers and case managers with intermingled job responsibilities. The social workers assess the patient’s environmental and social issues, while the case manager’s focus on the medical barriers preventing discharge. The entire team then meets every morning to brainstorm possible solutions to overcome those barriers. The social workers and case managers continue to communicate with each other during the day to develop appropriate discharge plans.
The physician advisor is also in constant communication with our team. We meet weekly with our physician advisor to discuss the patients’ care plan, LOS, and barriers to discharge. This leads to further communication between case managers, social workers, physician advisor, and attending physicians.
If you are not communicating as a team, you will not be successful in decreasing LOS. And in the end, it is the patient that loses out. I am lucky to have such a great team of case managers and social workers. Together we continue to strive to make our great team even better. Get engaged with your case management team today!
Communicate with coders to assign proper discharge codes
Proper assignment of discharge codes can make a big difference in a hospital’s reimbursement. Unfortunately those who know most about discharge plans—case managers—are not always responsible for assigning these codes.
Assigning the correct MS-DRG requires reporting the patient’s age, gender, discharge status, principal diagnosis, secondary diagnosis and procedures performed. The discharge status has equal weight with diagnosis and procedures, and not everyone appreciates that, according to a Curaspan Connections article entitled “Closing the Gap Between Case Managers and Coders” written by Jackie Birmingham, RN, BSN, MS, vice president of regulatory monitoring and clinical leadership at Curaspan Health Group.
Coders are ultimately responsible for assigning discharge codes. They typically rely on what the physician initially ordered for postacute care. However, the case manager who facilitates the transition of care may have additional information that is valuable to the coders—including where the patient ultimately went, what level of care the patient received, and when the services began, Birmingham wrote. Failing to communicate that information can lead to an inaccurate claim, which can result in financial or legal penalties.
Transfer DRGs
Assigning the correct discharge code is particularly important with respect to transfer DRGs, which are subject to transfer rules that can lead to reduced reimbursement. Most notably, if a patient is a assigned a transfer DRG and is discharged to non-IPPS postacute facility following a short stay, the hospital may receive a reduced payment.
For example, if a patient is discharged to a SNF to receive skilled care (code 03) before his or her stay reaches the geometric mean LOS (GMLOS), the hospital will receive a reduced payment. However if that same patient receives basic care at the SNF, the hospital would receive a full DRG payment. The difference could mean thousands of dollars.
For more information about discharge status codes and transfer DRGs, read the “Pay attention to transfer DRGs and discharge status codes” article in the February issue of the Case Management Monthly newsletter.
Download the Patient Discharge Plan form
Diana Cripe, MSW, director of case management at Morton Plant Hospital in Clearwater FL was kind enough to share her facility’s Patient Discharge Plan form in the November issue of Case Management Monthly.
Each inpatient has a Patient Discharge Plan form that the multidisciplinary team marks throughout his or her stay. Looking at the form, patients can easily see the problem they presented with, the care they received while in the hospital, and the specific healthcare goals they need to monitor after they leave.
Patients can present the form to care providers at follow-up appointments to give the provider an idea of what went on during the patient’s hospital stay.
Happy Case Management Week
Case managers, this week is your time to shine.
National Case Management Week is your opportunity to tell everyone else what you and you fellow case managers already know; case managers are an essential part of hospital operations. Whether it’s helping physicians determine level of care, reviewing orders for medical necessity, ensuring proper use of resources, setting discharge plans for patients, or helping prepare RAC appeals, case managers are involved in patient care from door to door.
If you are looking for National Case Management Week posters, banners, and pins to help spread the word check out the American Case Management Association’s National Case Management Week catalog.
The Case Management Society of America (CMSA) also put out a 20-page packet that is full of ways you can raise case management awareness:
- Offer to speak at community events on case management.
- Write letters to your local paper. Contact radio and TV stations to let them know about National Case Management Week.
- Write a guest editorial to newspapers, journals or magazines regarding the positive impact of case management.
- Distribute a press release announcing National Case Management Week.
This is not an exhaustive list. See the full list of suggestions at the CMSA Web site
What are your plans for National Case Management Week?
Improve communication between physicians and case managers to prepare for reform
No one is really sure what is going to happen with healthcare reform, but we can be pretty sure today’s reimbursement model and treatment plans will be different tomorrow.
Currently, payers use a fee-for-service model. In the Medicare population, providers receive payment for inpatient stays according to a DRG. Commercial payers pay hospitals based on either a DRG system or a percentage of billed charges.
Healthcare reform will eliminate the fee-for-service model and create a world where payers bundle hospital and physician payments. That payment model will then evolve into an “episodic” payment plan where facilities and providers are paid one fee for a episode of care provided within a 60-90 day window. There is a fixed dollar amount for that episode, no matter what treatment is provided or whether the patient is readmitted during that time frame. From there, payment will move to a capitated model where providers received a flat fee for each patient, with percentage increases for top quality scores and other metrics. While all these changes are going on, accountable care organizations (ACO) will be forming.
An ACO is composed of one or more hospitals and physician groups that work together using evidence-based care to improve the quality of care, while controlling costs. The Medicare Payment Advisory Commission (MedPAC) an entity that reports to Congress, is continually researching and monitoring the ACO concept.
Case management’s role
Over the years, communication between physicians and nurses has greatly improved. For example, the physician used to simply tell the case manager and/or social worker to set up a SNF placement. Now, the case manager or social worker creates a discharge plan upon admission and discusses the appropriateness of the plan with the physician.
However, there is still room for improvement. Physicians and nursing staff have communicated at each other, but not necessarily with each other in determining the plan of care. One example of the opportunity for improved communication is when a physician writes an order for a test. It is essential for case managers to discuss with physicians whether it is necessary to keep the patient in the hospital for the test or whether the test can be completed as an outpatient.
Under healthcare reform, the communication and relationships between physicians and nurses will need to be integrated. It will be imperative for case managers and physicians to work as a team to maintain collaboration and quality care of the patients. They will need to work together to provide proactive discharge planning and patient education. They will need to team up to provide necessary tests and treatments, while making sure they use resources appropriately.
The healthcare organization I work for is very proactive in its healthcare reform planning. The organization provides education to physicians and involves them in the planning process for the future of healthcare. Our senior case management team is already creating processes and education that will provide opportunities to begin physician and case management integration, starting with our ED physicians. The minute the patient enters our healthcare organization, case managers and physicians begin to collaborate.
What is your organization doing to prepare for healthcare reform? If you do not know, find out. Now is the time to get involved in preparing your organization and healthcare team for what is ahead.
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?
Tailor discharge instructions to your patients’ needs
The issue of readmissions isn’t new, but the attention it’s receiving is. With new regulations, incentives for reducing preventable readmissions are not only aligned, but imperative for providers.
Preventing unnecessary 30-day readmissions is a complex issue. The solution should be formulated with evidenced-based best practices. Next, the team must identify those patients at greatest risk for readmission. Key success factors include the following:
- Effective communications between healthcare delivery team members
- Proactive discharge planning between the care team and the patient
- Customized discharge instructions that are meaningful to the patient’s unique needs and lifestyle
Communication is an obvious component of discharge planning. Caregivers may communicate the correct information repeatedly to patients, but if patients can’t comprehend or apply the information to their own situations, it’s like speaking another language.
We, as caregivers, should take time to read our patients’ body language. Is the patient engaged and connected to what we are sharing with respect to their discharge needs or are they more focused on having their IV access removed and securing a ride home?
Hospital staff must deliver discharge instructions in a way that the patient can comprehend and comply with. This may require being very creative, depending on the patient’s needs. Hopefully, a standardized technology solution will soon enable us to tweak discharge instructions based on patients’ learning levels and specific needs.
An innovative start – Before our time
In 1995, while serving as a Nursing Director for several inpatient units, I developed a unit based council (UBC) of 10–12 highly respected RN. The UBC ultimately became the decision-making body for the 32 bed nephrology inpatient unit of a large medical center. They obtained feedback from the unit’s staff and made decisions that best served the patients and met the needs of the staff, physicians, and other customers.
After we implemented other initiatives, for example, working with the physicians to change the time that vital signs were taken to minimize interruptions to the patients, it was time to address the high rate of readmissions. The organization didn’t have a case management program, so the UBC and I decided to convert a 0.8 RN fulltime equivalent position into an outpatient (OP) case manager role. After reading various articles regarding OP case management and disease management, the UBC and I drafted a job description and program goals. [more]
