All Entries Tagged With: "length of stay"

Understanding the insurance company case manager’s goals can help hospital case managers

While discussing a hospital admission with a case manager employed by a well-recognized national third-party payer, I learned of an interesting revelation that case managers may wish to take note of.

Each insurer-employed case manager is charged with meeting a monthly average length of stay goal set by the individual hospital as well as the aggregate hospital. The insurance case manager receives a weekly report of cases that achieved average length of stay compared to individually-assigned average length of stay goals and objectives. To this end, the case manager knows at any given time where he or she stands in regards to meeting the assigned goals for hospital length of stay.

This insurance company case manager informed me that he is reminded on a regular basis of the ramifications of not meeting the established monthly length of stay goals. In extreme situations, insurance companies will terminate case managers that do not meet objectives.

Depending on the time of month and how the insurance company’s case manager is faring, hospital case managers can expect different volumes of cases designated for medical director review and potential medical necessity denial. There exists a certain realism that insurer case managers and medical directors may err on the side of conservatism when using Interqual or Millman care guidelines and clinical judgment to determine denial of inpatient stays. The bottom line is hospital case managers will need to take inventory of their communication skills and core competencies, including drafting of effective, succinct denial appeal letters—if the hospital charges him or her with doing so as one of their duties.

In this context, hospital case managers should track and trend denials communicated by insurer case managers and understand these case managers need to achieve pre-established average monthly length of stay goals. Hospital case managers must prepare for increased inpatient stay denials given the current economic climate of private health insurers, decreased member covered lives, and resulting decrease in health insurance premium income. Increased medical loss ratios and the number of uninsured and underinsured patients seeking care through the emergency room with subsequent need for inpatient admission can also add to the number of denials.

I am certainly not advocating for case managers assuming additional work. At many hospitals, the administration assigns new tasks and assignments to case managers with the rationale being case managers already “review the record” and thus have the time to take on new responsibilities. Unfortunately, the case management function has become so convoluted that case managers find themselves regularly performing duties that questionably contribute to the role of case management. However, I am advocating for their development and reinforcement of core competencies and skill sets in the art of “forceful” communication and negotiation.

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.

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.

Audio update: Managing LOS

As pay for performance and Recovery Audit Contractor investigations gain a greater bearing on the amount and expediency of reimbursement, managing length of stay (LOS) has become even more crucial for case managers. While responsibilities of case managers expand, an important measure of success continues to be managing LOS.

Many case management departments look at meeting a target number of days a patient stays at a facility, however, evidence has shown this may not yield the best outcomes when looking to manage and improve LOS. Inova Health System in northern VA, has had immediate and sustained success in reducing LOS through targeting clinical milestones. Its focus has been on improvement of the patient’s condition and minimization of avoidable complications, resulting in improved quality of care and a proven reduction in LOS.
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CMW Tip of the Week: Hospitalists reduce length of stay

Hospitalists create a win-win situation for themselves and the hospitals they work in, says Toni Brayer, MD, on eMaxhealth.com.

Hospitalists are physicians who typically work as part of a hospitalist group that provides coverage to a hospital seven days a week, 24 hours a day. Hospitalists become the attending physicians for  patients in the hospital—but only while they are in the hospital. Patients return to the care of a primary care provider after the hospital stay.

Brayer notes hospitalists often make more money working in the hospital than having their own practice. They are paid more by the hospital than they would receive by billing Medicare or Medicaid, and have no practice costs or employees to manage.

Additionally, hospitals with hospitalists programs have guaranteed coverage in the emergency department, better standardized protocols of care, and reduced length of stay.

Read the full article here.

Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!