All Entries Tagged With: "LOS"

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!

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.

Medical necessity—It’s a physician thing

Medical necessity for inpatient hospitalizations—or lack thereof—is a contentious topic that case managers face on a daily basis. The patient’s clinical presentation to the ED, severity of illness, physician assessment, or proposed plan of care does not always establish medical necessity.

When the patient meets the parameters of medical necessity at admission, he or she often reaches medical stabilization, thus meeting criteria for safe discharge. However, physician resistance can sometimes stand in the way of an appropriate discharge. Physicians may wish to watch the patient an additional day or may acquiesce to a patient’s desire to stay one more day.

Competing forces

While case managers and physicians have long battled over adherence to reasonable standards of medical necessity, several factors have made promoting efficient use of hospital resources through physician education all the more important:

• Dwindling third party-payer reimbursement
• More aggressive insurance company nurse reviewers
• Increasing numbers of uninsured or underinsured patients presenting to the hospital

However, competing financial incentives make it challenging for case managers to instruct physicians to adhere to medical necessity standards and use resources efficiently.

Physicians receive payment for their evaluation and management (E/M) services, while placing providers at financial risk through the admission and continued stay process, regardless of medical necessity. Physicians account for up to 20% of the healthcare dollar expenditures through face-to-face patient encounters. They also account for up to 90% of dollar expenditures through orders for services such as home health, physical therapy, and radiology and laboratory tests. [more]

ACE demonstration project could change how CMS pays hospitals and physicians

Before CMS institutes a new national regulation, it often tests it on a smaller group. These demonstration projects identify weaknesses in the new rules and allow CMS to make necessary tweaks and changes. Demonstration projects also allow other facilities that are not involved in the project to learn from their peers. A recent example of this is the Recovery Audit Contractors (RAC) demonstration period.

One of the current demonstration projects that could have a large effect on case management and coordination of care is the Medicare Acute Care Episode (ACE) Demonstration project.

Essentially ACE changes how Medicare pays for healthcare services. Instead of paying the hospital and physicians separately, CMS bundles both payments into a lump sum. The payment system operates much like the DRG system where the one payment will cover the patient’s entire stay, rather than each individual service.

Extending the DRG concept to pay for physician services would encourage physicians to work with hospitals to control costs and improve quality, stated the June 2008 Medicare Payment Advisory Commission’s Report to Congress: Reforming the Delivery System.

I spoke with a source who was excited about the idea of bundling payments. The source said physicians are currently paid for every day they see a patient so they really don’t have any incentive to keep LOS down. But the ACE program would make it so physicians have the same motivation hospitals have to effectively use resources and provide proper care in a timely manner.

Some physicians are skeptical of the idea. Some fear that the lump sum allows the hospital to control physician rates and possibly encourage hospitals to withhold certain services to keep costs down, according to a recent article published by the AMA.

CMS is conducting the ACE demonstration project is in Medicare Administrative Contractor (MAC) Jurisdiction 4 (Texas, Oklahoma, New Mexico, and Colorado).

Anyone who is at a participating facility and would like to discuss the program, please contact me (bamirault@hcpro.com). I am also interested to hear how folks that aren’t participating think this program could affect case management.

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.

ACMA conducts an Important Message from Medicare survey

The American Case Management Association (ACMA) Public Policy Committee surveyed nearly 400 case management professionals regarding the second notice of the Important Message (IM) from Medicare .

Based on the data, the key findings were as follows:

• The majority of respondents (84%) report that case management is responsible for issuing the second IM
• More than half the respondents (59%) report that 10 minutes or less are required to issue each IM
• More than 77% of respondents report that they track IM compliance
  • Of those who track IM compliance 40% report a compliance rate between 76% and 100%
• Only 38% of respondents report increased numbers of appeals
• The majority report that less than 25% of patient appeals are successful

The ACMA questioned respondents about the need or benefit of the second IM. Respondents said patients and family do not like being asked to redo the same tasks and use phrases such as: annoyed, waste of time and paper, frustrated, and signing more papers, to express their dislike.

Other comments said patients and families sometimes abuse the IM regulation in order to gain enough time in the hospital to qualify for skilled nursing care.

According to the ACMA, the findings will be released to ACMA members and non-members who participated in the survey.

Read more about the survey at the ACMA Web site.

Medicare deductibles and coinsurance for CY 2010

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., wrote the following post. It was originally published on the MedicareMentor blog. Read the original post here.

CMS recently published the Part A deductible and coinsurance and Part B deductible amounts for CY 2010.  For most covered inpatient stays, as well as covered outpatient services, Medicare does not pay the entire Medicare allowable for those stays or outpatient services.  Beneficiaries generally are responsible for a portion of the Medicare allowable in the form of deductibles and/or coinsurance.

Under Part A, Medicare beneficiaries are entitled to 90 regular benefit days per benefit period. Regular benefit days renew whenever a new benefit period begins.  That is, a patient once again has 90 covered inpatient days every time a new benefit period begins.  Medicare beneficiaries are also entitled to 60 lifetime reserve days, which may be used after regular benefit days for that benefit period have been exhausted.  Lifetime reserve days do not renew.  Once used, they are gone forever.

A benefit period begins with the first day on which a patient is admitted to an inpatient hospital or a SNF to receive services.  That benefit period continues until there is a 60-consecutive-day period during which the patient is not an inpatient in either a hospital or a SNF.  (With respect to the latter, the benefit period does not close as long as the patient is receiving skilled care as an inpatient in the SNF.)

For the first 60 covered inpatient days during a benefit period, the beneficiary is responsible for one inpatient deductible.  The applicable inpatient deductible is the one in effect during the calendar year in which that benefit period begins.  For inpatient covered days 61-90, the beneficiary is responsible for a daily coinsurance amount equal to 25% of the applicable inpatient deductible.  If a beneficiary exhausts (uses up) his regular benefit days, he may then draw upon any remaining lifetime reserve days.  For each lifetime reserve day, the beneficiary is responsible for a daily coinsurance amount equal to 50% of the applicable inpatient deductible. With respect to the coinsurance calculation, the coinsurance amount is based on the deductible applicable for the calendar year in which the coinsurance days occur.

The following is an example of how these rules would apply to an inpatient stay that begins in December of one year (2009) and ends during the following year (2010):

Assume that this was the first inpatient admission during the benefit period and that the beneficiary remained in the hospital for 61 covered days.  Because the benefit period began in 2009, the deductible for 2009 (the year in which the benefit period began) would be applied, in the amount of $1068.00.  This is the only amount for which the beneficiary would be liable for the first 60 covered days.  He would then be responsible for an additional single day’s coinsurance for day 61, in the amount of $275.00, which is the coinsurance amount for covered days occurring during 2010.  Thus the beneficiary’s total liability for this stay would be $1343.00.

Hospitals are advised to assure that applicable deductible and coinsurance amounts are applied to each inpatient stay, particularly those that cross over from one calendar year to another.

Denial Management – how strong is your process for concurrent denials?

We are evaluating our denial program only to assess that it was not as strong as we would like. As case management departments prepare for upcoming Recovery Audit Contractor (RAC), retro denials from health plans, and concurrent denials.
Our case management department looked at our process and it became clear that our management of our inpatients denials lacked process delineation. We began to re-assess this specific process as well as redefine our entire denial program.
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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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CMS, RACs, POA, LOS–but what about the patient?

Boy is healthcare ever on a fast track and getting more complex and confusing. There are new and revised regulations coming from the Centers of Medicare and Medicaid Services (CMS), and the Recovery Audit Contractor (RAC) implementation has us going to more meetings than we know what to do with. Let’s not forget about Present on Admission (POA) and we need to be monitoring those lengths of stay (LOS). Don’t get me wrong, these are all very important, high priority issues, but what about the patient?
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