All Entries Tagged With: "Discharge Planning"
CMW news: Incomplete discharge summaries to blame for preventable errors
A study released by the Indiana University School of Medicine finds that hospital discharge summaries lack information important to patients’ continuity of care.
Indiana University School of Medicine researchers published their findings in the September issue of Journal of General Internal Medicine under the title Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers.
The researchers reviewed 668 discharge summaries from two academic medical centers. They found that the hospitals discharged nearly 41% of the patients with test results pending—9% of those tests required changes with respect to patient care. However, the hospitals documented only 16% of those tests in patient discharge summaries. Only 13% of summaries included all pending tests.
Researchers say without that information, primary care physicians can’t provide the appropriate care patients need after discharge.
"Errors in communication reportedly contribute to over half of all preventable adverse events and are associated with twice as many deaths when compared with errors due to clinical inadequacy,” researchers conclude in their report.
Source: American Academy of Professional Coders and American Medical Association
Whiteboards help communicate across departments
Placing whiteboards at the foot of the patient’s bed was innovated by Planetree, a not-for-profit organization that works with hospitals to improve the patient experience and it has spread across the country. Unfortunately, in most hospitals whiteboards stand blank except for some flower doodling. That’s a shame because whiteboards are a fantastic way for departments to talk to one another and the patient about the plan of care in a simple, direct, way.
The intent of whiteboards is much more than simply identifying discharge dates and times. The whiteboard is meant as a means of communicating the plan for the patient’s day—what tests, what new procedures, and medications the patient can expect on a given day. Just think, different caregivers can walk into a patient’s room and in a glance see what the attending physician has prescribed for the day. For the patient’s benefit, information written on the whiteboard should be in layman’s language. Patients don’t know what NPO stands for.
Using the whiteboard as a means to inform everyone of the patient’s targeted discharge is example of making sure everyone is on the same page regarding progression of care plans for the patient. According to nurses and case managers I have spoken with, the feedback from patient families is consistently positive.
However physicians are not always excited about whiteboards. In one client hospital, physicians were annoyed and complained to the CEO when staff members started using whiteboards to write patients’ plan for the day and targeted discharge. He was seriously thinking of putting a stop to their use, but the physicians’ complaints were quickly over-taken by the number of complements he received from patients, families, and hospital caregivers. Even dietary and housekeeping staff members endorsed the practice. So, the CEO told the grumbling physicians to learn to deal with it….they are staying.
Does you facility use whiteboards? If so please share the ways you use them to communicate and how you handle HIPAA concerns.
Lessons learned at the Case Management Administrator Intensive Workshop
This week I took the opportunity to learn more about the case management profession and get a sense of what issues case management administrators are struggling with. I spent Monday and Tuesday of this week attending The Center for Case Management’s Case Management Administrator Intensive Workshop in Boston. It was two info-packed days and at the end I emerged from the convention center with enough story ideas to get me through to next spring.
Here are a few quick nuggets of wisdom I took from the workshop:
- The group at the workshop represented a great cross section of the national case management scene, which made for a well-rounded discussion. There were representatives from small non-profit facilities and large hospital systems. Some flew in from the west coast, others drove up the east coast, and one case manager even made the trek from Taiwan.
- The attendees had a laundry list of issues they struggle with everyday including:
- Creating data dashboards
- Recruiting and retaining staff in a tough economy
- Structuring transfer agreements
- Creating a utilization review committee
- Using condition code 44
- Defining case management and social worker roles
- Karen Zander RN, MS, CMAC, FAAN, principal and co-owner of the Center for Case Management had a great simile for case managers. She called them the immune system of the hospital. Much like the immune system, case managers typically keep all the hospital’s functions working properly while going relatively unnoticed. However, when the hospital gets sick (e.g. denials increase, patient satisfaction goes down, readmissions go up, etc.) they quickly come to the forefront.
- Tina Davis, RN, MS, CNS, CMAC, said “The RAC solution is in case management.” What she meant is that a strong case management program can prevent many of the issues RACs commonly search for including medical necessity, level of care, condition code 44, proper MS-DRGs, and readmissions.
- Kathleen Bower, DNSc, RN, FAAN co-owner of the Center for Case Management urged the attendees to make case management a data driven department. Data supports what the case management department does for the hospital’s bottom line. With data, case management administrators can negotiate more resources for the department, assess new policies and practices, and demonstrate the value of the department.
- Bonnie Geld, MSW, advised that case managers should not limit their knowledge of a case to what is on the record. Geld said case managers should “go see, touch, smell, and speak to the patient.” Taking the time to interact with a patient early and often can help develop a discharge plan that takes into account the patient’s family, economic, and mental status.
One bad run-in shouldn’t define entire field of case management
Editor’s Note: I came across this letter to the editor that Nancy Sullivan, Director Case Management Massachusetts General Hospital Boston, submitted to the Boston Globe in response to an op-ed column that spoke negatively about case managers. I would like to thank Nancy Sullivan for allowing her letter to also appear on the Case Management Mentor blog.
In her op-ed “The ‘quicker and sicker’ exit strategy’’ (July 30) Deborah Schuss describes her family’s negative – and indeed, unacceptable – encounter with a case manager. One patient’s bad experience, however, should not define an entire field.
As trained and experienced nurses, social workers, and other health professionals, case managers work diligently and compassionately to ensure a safe transition for patients from the hospital to the next setting of care or home. Case managers serve as trusted guides during a period of uncertainty and change, helping families sort out details of ongoing care, and arranging for services after discharge.
As essential members of the patient care team, case managers advocate for the patient and family as they collaborate with physicians, nurses, and others. And while case managers help ensure that care is delivered in a timely and cost-effective manner, their decisions are driven by what is in the patient’s best interest.
I am privileged to witness each day the impact of case managers. One grateful patient wrote that his case manager “went out of her way to do detailed planning about my discharge, checked in with me regularly, was patient with all the questions I had, and reached out to my wife in addition to myself.’’ A family member expressed deep appreciation to a case manager who had spent extraordinary time arranging medical care in Florida so that a terminally ill young mother could travel to Walt Disney World with her children.
These are the case managers I know – true representatives of a profession I am proud to be part of.
Nancy Sullivan
Director Case management Massachusetts General Hospital Boston
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]
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]
Optimizing patient flow to protect against the RAC
Waits, delays, and cancellations are so common in healthcare that patients and providers have come to expect waiting as part of the care process. But poor patient flow can have seriously adverse effects on patient outcomes and your facility’s bottom line—and can even increase your susceptibility to RAC audits.
According to Kelly Cooke, MSN, RN, the director of clinical resource management, social work, and documentation improvement at the Hospital of the University of Pennsylvania, part of maintaining optimal patient flow is placing patients in appropriate level of care and creating a system that guards against readmissions.
“If you can initially place your patients in the appropriate level of care, this will enable your facility to have a very successful RAC audit,” says Cooke. In addition to up-front processes, she recommends creating strategies to prevent unnecessary readmission.
In the April 27th HCPro audioconference, Optimize Patient Flow Through Case Management: Maintain Revenue Integrity and Joint Commission Compliance, Cooke, along with patient flow experts Derenda S. Pete, RN, MBA, and Brooke Wollenberg McDonnell, MBA will discuss how Hospital of the University of Pennsylvania created 25 virtual beds and have created a system that not only keeps them RAC ready, but has allowed them to gain, on average, four hours on each discharge. The audioconference will also offer strategies for dealing with inappropriate admits, information on how to manage the uninsured and underinsured, tips on how to collect, analyze, and distill data to improve outcomes, and suggestions on how to communicate with physicians on appropriate admission criteria.
Discharging planning: When an LTACH makes the most sense
I recently received this question from a colleague:
Mrs. B is expected to need acute care for three to four weeks. There is a bed in a licensed Long Term Acute Care (LTACH) hospital but the family refuses that placement, since it’s an 80-mile drive. We don’t know what to do.
To answer your question: This issue is best resolved with the Utilization Review chairperson (a physician) who works with the patient’s physician. Here are two references: the Social Security Act for Discharge Planning and CMS-10, the Medicare Hospital Manual. In section 290.3 section C of CMS-10, it reads:
Admitting patients to “inpatient status”
I received a question recently about admitting patients to “inpatient status.” This was specifically related to a patient who is in the Emergency Department, and a physician writes the order “admit to inpatient;” the patient remains in the ED waiting for a bed (they may be considered an ED boarder).
From what I found in the reference below–found on the CMS website–the patient is considered “admitted to inpatient” when the order is written (dated and timed). For patients in observation being admitted to inpatient, this fact can have an impact on whether he/she was on the midnight census of the admitting date – which can then count toward the 3 day acute inpatient day making him/her eligible for extended care benefits.
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Challenges for case managers in discharge planning
Discharge planning is a constant state of mind for our case management team. We continually strive to create a plan that is safe and comprehensive.
Discharge planning is also a major focus of accrediting agencies including both The Joint Commission (formerly JCAHO) and the Centers for Medicare & Medicaid Services (CMS). Our case management team has found that creating a safe discharge plan and initiating a thorough multidisciplinary assessment (including functional, psychological, and cognitive) within the first twenty-four hours has been a challenge. The challenge in safe discharge planning is usually the coordination of critical communication of all team members.
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