Case Management Monthly

Transcription

1 Best practices and practical solutions Case Management Monthly P4 P6 Transitional care makes a difference A new study finds that providing transitional support to high-risk patients has a significant impact on reducing readmissions. Seeing RED Learn about a program designed to help hospitals implement strategies to reduce readmissions. Complex case Thinking creatively to help a terminal cancer patient find treatment closer to home. From the Director s Desk Use these strategies to encourage your staff to get flu vaccinations. Volume 10 Issue No. 11 November 2013 The 2-midnight inpatient presumption: How to put it into practice Learning objectives At the completion of this educational activity, the participant will be able to: Define the two-midnight inpatient presumption rule and other changes to inpatient admission outlined in the 2014 IPPS Final Rule Identify at least one method to implement the new rule at your facility By now you ve probably gotten a good look at the 2014 IPPS Final Rule changes to the inpatient admission guidelines, which CMS released in August. It s time to put these changes into practice. The revisions will definitely require some adjustments to the way physicians and case management staff members perform these admissions, says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, Okla. CMS goal with this final rule was to provide greater clarity and to help doctors determine when inpatient admissions are appropriate for a Medicare Part A patient. CMS also took this step in response to concerns from beneficiaries who have reported long hospital stays as outpatients, which can be most costly for them and affect their ability to get coverage for needed follow-up care, according to a press release issued by CMS. Trendspotting 20% High-risk Medicaid patients who received transitional support after hospital discharge were 20% less likely to be readmitted. 21,375 The study on transitional support looked at 21,375 patients with chronic medical conditions that put them at high risk for readmission. 14% The study found that 14% of Medicare beneficiaries have six or more chronic conditions and account for 70% of all Medicare readmissions to the hospital. Source: Health Affairs.

2 Case Management Monthly November 2013 This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. editorial advisory board Senior Managing Editor Jay Kumar Jackie Birmingham, RN, BSN, MS, CMAC Vice President Emeritus, Clinical Leadership Curaspan Health Group, Inc. Newton, Mass. Stefani Daniels, RN, MSNA, CMAC, ACM President and Managing Partner Phoenix Medical Management, Inc. Pompano Beach, Fla. Wendy DeVreugd, RN, BSN, PHN, FNP, CCDS, MBA Regional Senior Director of Case Management Kindred Healthcare, Hospital Division, West Region Westminister, Calif. Deborah K. Hale, CCS, CCDS President Administrative Consultant Service, LLC Shawnee, Okla. Robert Marder, MD Practice Director of Quality and Patient Safety The Greeley Company Danvers, Mass. Contributing Editor Kelly Bilodeau Peter C. Moran, RN, C, BSN, MS, CCM Nurse Case Manager Massachusetts General Hospital Boston, Mass. Loretta Olsen, MSN, RN, ACM Director of Case Management Mercy Medical Center North Iowa Mason City, Iowa June Stark, RN, BSN, MEd Director of Case Management, Social Work, and Support Services Tufts Medical Center Boston, Mass. Karen Zander, RN, MS, CMAC, FAAN Principal and Co-Owner The Center for Case Management, Inc. Wellesley, Mass. Case Management Monthly (ISSN: [print]; [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA Subscription rate: $349/year. Case Management Monthly, P.O. Box 3049, Peabody, MA Copyright 2013 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or Visit our website at com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of CMM. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. CMM is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Quick Hits Online Colorado initiative focuses on reducing readmissions An initiative between the Colorado Hospital Association and United Healthcare has reported success in reducing the readmission rate for same cause patients, according to the Denver Post. Same-cause patients are those who are readmitted with the same illness as their initial visit; the same-cause readmission rate at 19 Colorado hospitals dropped to just over 5% from 9.8% the year before. Missouri hospital pilots new readmission program Cox South Hospital in Springfield, Mo., has launched a new pilot program in its cardiac and pulmonary departments designed to reduce the readmissions of recently discharged patients, according to the Springfield News-Leader. When a new cardiac patient is admitted, staff determine whether the patient is at high risk of being readmitted within 30 days. The hospital provides extra attention to patients labeled as high-risk, including individualized meetings with a pharmacist and nutritionist. Follow Us Follow and chat with us about all things healthcare compliance, management, and Questions? Comments? Ideas? Contact Senior Managing Editor Jay Kumar at jkumar@hcpro.com or , Ext from the field One [patient financial services] director told me that I d be crazy to submit an inpatient claim just because the patient was here two midnights, unless the utilization review coordinator confirmed that the documentation justified inpatient medical necessity. Stefani Daniels, RN, MSNA, CMAC, ACM stay connected CMM in Your Inbox Sign up for any of our 17 newsletters, covering a variety of healthcare compliance, management, and reimbursement topics, at Don t miss your next issue If it s been more than six months since you purchased or renewed your subscription to Case Management Monthly, be sure to check your envelope for your renewal notice or call customer service at Renew your subscription early to lock in the current price. Relocating? Taking a new job? If you re relocating or taking a new job and would like to continue receiving Case Management Monthly, you are eligible for a free trial subscription. Contact customer service with your moving information at At the time of your call, please share with us the name of your replacement. 2 hcpro.com 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

3 November 2013 Case Management Monthly The percentage of patients doctors assign to observation services has risen in recent years. A July 2012 Health Affairs study showed that between 2007 and 2009, physicians assigned an increasing number of Medicare patients to observation services, while the number of inpatient admissions simultaneously dropped. The ratio of observation to inpatient stays increased 34% in that time period. But will these new changes help clarify which patients should be assigned to observation services, and which should be inpatients? The answer isn t clear yet. Some say that the new requirements will just create an additional burden on physicians. The same words keep cropping up... crazy; doesn t help; burdensome; documentation, documentation, documentation, says Stefani Daniels, RN, MSNA, CMAC, ACM, managing partner at Phoenix Medical Management, Inc., in Pompano Beach, Fla. Below are some highlights of the changes and some strategies from our experts to help you implement them. 2-midnights provision CMS added a new provision that says if a physician admits a patient on an inpatient basis, because he or she anticipates that the patient will need to complete an inpatient stay lasting for two midnights, CMS will presume that the stay is medically necessary. Rather than an expectation the patient will require more than 24 hours of care [current rule], there must be an expectation the patient will require at least two midnights of inpatient hospital care, says Hale. But will this really change the thought process when a physician is determining the patient assignment? I can tell you that no one I ve spoken to, and nothing I ve read, indicates that anyone is going to change anything, says Daniels. Unless documentation clearly indicates that inpatient treatment is justified, it doesn t matter how many days the patient is in the hospital. One [patient financial services] director told me that I d be crazy to submit an inpatient claim just because the patient was here two midnights, unless the utilization review coordinator confirmed that the documentation justified inpatient medical necessity, she says. Formal inpatient order In addition to considering the two-midnights criteria, the physician must also complete a formal inpatient order when admitting a patient as an inpatient. This order must be written before the patient is admitted and it cannot be retrospective, according to June Stark, RN, BSN, Med, director of care coordination, St. Elizabeth s Medical Center in Boston. The physician is, however, allowed to consider all the time a patient has already spent in the hospital as an outpatient receiving observation services, or in the emergency department, operating room, or other treatment area in guiding his or her two-midnight expectation, according to a CMS press release. The physician order certifies that the inpatient services followed Medicare regulations, says Stark. Physicians must use specific language in the order, including the following: The reason for inpatient services, either the reason for the hospitalization of the patient for inpatient medical treatment; or medically required inpatient diagnostic study or special or unusual services for outlier cases The estimated time the beneficiary is required to be an inpatient, as it relates to the two-midnights requirement Plans for post-hospital care with discharge instructions, if appropriate It s important to note that a physician must write the order before the patient is formally admitted, but the inpatient admission does not begin until the time the patient is actually formally admitted to the hospital. CMS does permit physicians to provide verbal orders, says Stark. And a verbal order can be written by an individual who does not actually have the authorization to admit patients to the hospital; however, they must have credentials and privileges to take a verbal order, says Hale. The order can be written as admit to inpatient v.o. (or to ) Dr. Smith and Admit to inpatient per Dr. Smith, says Stark. Delegating responsibility Another change under the new rule is that physicians 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or hcpro.com 3

4 Case Management Monthly November 2013 can no longer delegate the responsibility for determining whether a patient should be admitted as an inpatient or placed in observation to any other clinician, unless that individual has admitting privileges. This prevents the use of the case management protocol, says Hale. The physician who is responsible for the patient must sign the order. Another physician can also sign it, but he or she must have knowledge of the case and the authorization of the responsible physician, says Stark. The hospital medical staff may also make this authorization. Providing a certification statement The new inpatient criteria require that the physician complete and sign a certification statement before the patient is discharged, according to Stark. The physician certification must include the physician order and other documentation in the medical record as evidence that hospital inpatient services were reasonable and necessary, she says. This statement must detail the following: The clinical rationale for inpatient admission Expected length of stay Discharge plan Physicians are encouraged to admit patients based on a potential diagnosis, rather than just a collection of symptoms, says Stark. Although this new requirement provides added detail it doesn t provide a guarantee that CMS will accept the claim. Even with this certification statement CMS states the physician order will be given no presumptive weight, says Hale. The physician order and certification are not considered by CMS to be conclusive evidence that an inpatient admission or service was medically necessary. The order must be supported by objective medical information for purposes of the Part A payment. Only a few people are authorized to sign the certification including the following, according to Stark: A physician who is a doctor of medicine or osteopathy A dentist in the circumstances per CMS A doctor of podiatric medicine, per state law Ultimately, your facility should review these new requirements to ensure that physicians and case managers are aware of the changes and have adopted new strategies to implement them. Some anticipate that these new documentation requirements may be cumbersome for physicians, says Daniels. During our conversation [one physician] said he s so distressed that he is going to break the family tradition and give up his hospital practice. He said, It s just becoming more trouble than it s worth. H Study: Patients who get support transitioning home experience fewer readmissions Learning objectives At the completion of this educational activity, the participant will be able to: Discuss the case manager s role when developing home interventions Identify possible ways to involve the case manager when planning home interventions High-risk Medicaid patients who received transitional support after hospital discharge were 20% less likely to wind up back in the hospital during the following year, according to a new study. The study, Transitional Care Cut Hospital Readmissions for North Carolina Medicaid Patients with Complex Chronic Conditions, was published in the August issue of Health Affairs. It focused on a statewide transitional care initiative that started in North Carolina in It looked at 21,375 patients with chronic medical conditions that put them at high risk for readmission. A portion of those patients, 13,476, received the transitional support services through the North Carolina initiative. The patients 4 hcpro.com 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 November 2013 Case Management Monthly in this group were on average older and had more chronic conditions and other risk factors than the traditional care group, according to study authors Carlos T. Jackson, Troy K. Trygstad, Darren A. DeWalt, and C. Annette DuBard. Researchers found that despite the fact that these patients were older and sicker, post-discharge support reduced their chances of requiring a hospital readmission. Benefits of the intervention were greatest among patients with the highest readmission risk, wrote study authors. One readmission was averted for every six patients who received transitional care services and one for every three of the highest-risk patients. The lessons learned during the course of this study can be applied to other high-risk Medicare patients. Fourteen percent of Medicare beneficiaries have six or more chronic conditions and account for 70% of all Medicare readmissions to the hospital, wrote study authors. Focusing on services provided The basic services provided to the study group included the following: Helping patient manage their medications Educating patients on self-care Ensuring timely outpatient follow-up These included strategies such as home visits, medication reconciliation, or hospital bedside visits, according to the study. Transitional support also involved providing post-discharge care providers with details about the hospitalization and any potential clinical or social needs that might cause problems for the patient. Evidence suggests that hospital discharge is a critical opportunity for care coordination interventions to prevent recurrent hospitalizations for patients with complex conditions, wrote study authors. Interpreting the results So what does this study mean to you? Jennifer Cockerham, RN, BSN, CDE, senior vice president for clinical programs, Community Care of North Carolina, says that the lesson case managers should take from this study is that the primary group that benefits from transitional care are those at highest risk for readmission typically patients with more than one chronic condition. This is the case not only because this group of individuals are generally sicker than other patients, but also because these patients often experience fragmented and uncoordinated care, she says. If these patients don t receive transitional care, they re at much higher risk of being readmitted. This further emphasizes the need to begin discharge planning at the time of admission, says Cockerham. Discharge plans should be patient-centered and include outpatient providers. They should also focus on making sure that outpatient providers get details about the patient s hospital stay in a timely manner, and that hospital representatives ensure follow-up with that provider shortly after discharge, she says. Although all facilities may ideally want to adopt a whole host of post-discharge initiatives to support patients, not all of them can afford to do so. If your organization needs to pick and choose where to put its dollars, Cockerham says further study will focus on which initiatives are the most effective. Continuing education information NURSES Contact hours for nurses are available, with 2.5 contact hours awarded each quarter: March, June, September, and December. To obtain your contact hours you must: Read each issue of Case Management Monthly within the quarter (e.g., April, May, and June 2013) Successfully complete and submit the quarterly quiz (offered in the March, June, September and December issues; passing score is 80%) Complete and submit the evaluation Each quarter s enduring continuing nursing education (CNE) expires after one year. Disclosure statement: The planners and authors of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. HCPro, Inc., is accredited as a provider of CNE by the American Nurses Credentialing Center s Commission on Accreditation HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or hcpro.com 5

6 Case Management Monthly November 2013 In the meantime, she recommends two initiatives that will likely provide a big payoff for patients: 1. Teaching patients how to take their medications. Ensuring that patients and families leave the hospital with a reconciled list of medications and an adequate understanding of how and why to take their medications is critical, she says. In addition, it s important to make sure that patients have access to their medications, understand changes related to their medications, and how to take them at home. This often requires a follow-up intervention in the PCP office or patient s home to view the medications and to review how well the patient understands directions and whether he or she is taking medications properly. 2. Scheduling follow-up appointments. Another priority intervention is helping the patient to schedule a follow-up appointment with his or her primary care physician within three to five days from discharge, says Cockerham. Patients frequently do not understand why they need to go to the doctor so quickly after leaving the hospital, she says. To reduce the risk of readmission, do the following: Arrange the appointment for the patient in a timely manner Ensure that the patient has transportation Educate the patient and family or caregiver on the importance of keeping the appointment Instruct patients to take all their medications, discharge instructions, and pertinent documents to the appointment This study provides some important answers about how to prevent readmissions. Take the time to review the results and consider applying some of these strategies to reduce readmissions among high-risk populations at your own facility. H Project RED: Supporting patient safety and preventing readmissions Learning objectives: Describe Project RED (Re-Engineered Discharge) Discuss methods to implement the Project RED strategies If you re looking to reduce your readmissions and let s face it, who isn t these days? it may be time to take some tips from organizations that have had success. One program that is producing results, in the form of 30% fewer readmissions, is Project RED (Re-Engineered Discharge). Project RED is a research group at Boston University Medical Center that creates and tests strategies to reduce readmissions. It s backed by the Agency for Healthcare Research and Quality (AHRQ). In the spring the group rolled out a new toolkit that can help hospitals implement 12 strategies that RED researchers have shown to reduce the risk of rehospitalization. These processes aim to improve the postdischarge transition for the patient, according to the organization s website. CMM recently spoke with Carli Meister, M.Sc. (A), RN, director, customer relations and risk at Chester County Hospital in West Chester, Pa., a 220-bed hospital that implemented Project RED. Chester County was one of 10 facilities that the AHRQ and Project RED leaders asked to try the Project RED program to find out: 1. If the program actually worked in a real-life setting 2. How Project RED researchers could improve the program Chester County began with a pilot program on its telemetry floor in 2011 and succeeded in reducing readmissions by 50% among patients discharged home. Below is a rundown of its process and some advice from Meister for facilities that may be looking to adopt Project RED or a similar program. The process Chester County officials began Project RED 6 hcpro.com 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

7 November 2013 Case Management Monthly implementation with education. The organization offered classes for all telemetry staff members involved in patient care, including physicians. The education focused not only on the program itself, but also on where the initiative fit into the big picture; for example, how it related to current trends toward value-based purchasing and readmission mandates. Organizers provided specific written materials to staff members in addition to the information provided in the Project RED toolkit. They offered additional nurse training on patient discharge education. Unit coordinators were enlisted to help patients make follow-up appointments with their physicians before they left the hospital. And a few physician champions were chosen to serve as liaisons to educate other physicians about Project RED during medical staff meetings. A Project RED task force was formed and began meeting weekly, which continues to the current time, says Meister. Other changes included: Enlisting a cardiovascular nurse navigator to make follow-up phone calls within 48 hours after discharge, using the Project RED script Visiting area physician offices to introduce the program and to discuss the process for making follow-up appointments. Due to the success of the program, Project RED is now used throughout the hospital, not just in the telemetry unit, says Meister. Advice for implementation One of the most important reasons for the success of the Project RED initiative at Chester County was that hospital administrators supported it, says Meister. Getting this leadership buy-in is critical to making the program work. The organization really must want to change its approach to transitions, says Meister. Project RED is a different way to envision care. It changes the way the organization views and responds when it s time for the patient to leave the facility. She also offered some other advice for facilities looking to implement the program, including the following: Take advantage of available resources. The Project RED website and the AHRQ are rich with resources, says Meister. For example, the Project RED website includes PDF forms and instructions on how to perform various states of the 12-step RED process. Don t let money be a barrier. Project RED doesn t have to be cost-prohibitive. For example, one of the components of the program calls for discharge educators, who are clinicians that teach patients self-care following hospitalization, says Meister. Rather than allocate funds to add new positions, Chester County improvised, training all the existing telemetry nurses and case management staff into that role. An important component of training was educating nurses about the teach-back method, which is a giveand-take style of educating patients. Rather than just reciting information, the goal is to start a conversation and to encourage the patient to ask questions and repeat the information the nurses have provided. Creating the After-Hospital Care Plan. One of the challenges with regard to Project RED is the creation of the After-Hospital Care Plan. This is a detailed document that includes all the information a patient needs to care for him- or herself after transitioning out of the facility. It includes everything from medication lists to instructions about diet and physician contact information. It s best to have an electronic system that can create this document, but that s not always easy to develop, says Meister. Organizations have a couple of options in this area. Hire a company that can create this electronic system for you. Create this system in-house. Use a Word document (see sample on p. 8). This option might work long-term if Project RED is only being used for one, small department. Chester County used a Word document during its pilot. But it s too cumbersome as a long-term option for a larger initiative, which is why Chester County went on to create its own system in-house, says Meister. H 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or hcpro.com 7

8 Case Management Monthly November 2013 Sample form Project RED: After-Hospital Care Plan Below is a portion of the After-Hospital Care Plan used by Chester County Hospital in West Chester, Pa. This document is provided to patients when they leave the facility to help keep all their pertinent information in one place. This care plan includes everything from medication instructions to physician contact information. After-Hospital Care Plan Please bring this packet with you to all follow-up appointments. Patient Name: Discharge Date: MR#: Acct #: If you have any questions about this plan, please call the nurse navigator at If you have any serious health problems or concerns, please call Dr. at. Please follow this schedule each day: Why am I taking this medicine? After-Hospital Care Plan: Medicines Name/amount How do I take this medicine? What else do I need to know? AFTERNOON MORNING Source: Chester County Hospital, reprinted with permission. 8 hcpro.com 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

9 Complex Case Finding hospice care close to home An 85-year-old woman named Olga comes into the hospital for treatment of severe pain related to terminal pancreatic cancer. Her family and friends are concerned, because her pain is becoming unmanageable, so her doctor decides to insert a pain pump to help relieve her severe abdominal and back pain. Until now, Olga has been living at home with support from her family, including her adult daughter and niece. But her disease has now progressed to a point where the case manager, Mary, believes that she is a candidate for hospice care. But there is one major problem. Because Olga lives in such a rural area, the type of care that she needs is only available in a city more than four hours from where she lives. Olga s daughter and niece both live close to Olga s home. They ve coordinated their work schedules so one of them is available to assist her. Olga s neighbor also helps out from time to time. A number of Olga s friends also participate in her care by regularly dropping off meals. The family accepts Mary s recommendation for home hospice care. However, upon pursuing this discharge option, Mary determines that hospice nurses won t be able to drive to Olga s home because it s four hours away. Now learning this, Mary does not want to put an additional burden on Olga s family and friends by placing her in a facility so far away. Mary consults with the director of case management and the two try to come up with a better option to get Olga hospice care closer to home. Mary knows that her busy rural hospital has a preference to utilize home or facility hospice, rather than using an in-hospital hospice option. However in this case, the two decide to make an exception for Olga and her family, arranging a hospice in-hospital stay for Olga at their own facility. They meet with hospital officials, and work with a case manager at Olga s insurance company to make the arrangements. Ultimately, both the facility and the insurance provider agree to allow Olga to receive hospice care at the hospital, where she will be close to her support system. Creative thinking allowed case managers to come up with a compassionate solution that made a difficult situation much easier for Olga and her family and friends. H Case Management Monthly From the Director s Desk Is your staff prepared for flu season? Flu season is here again and the Centers for Disease Control and Prevention (CDC) recommends healthcare workers get vaccinated to protect themselves and patients. But in 2010, researchers found that only 63.5% of healthcare workers followed that advice. Healthcare workers may resist getting vaccinated for a number of reasons from not wanting to get an injection to just being too busy. But because influenza can be spread a day before the infected individual has symptoms, it s easy to transmit to others, including hospitalized patients. Evidence shows that getting vaccinated is important. According to the CDC, healthcare providers who get vaccinated have a lower risk of the following: Transmitting influenza to others Missing work Getting sick or even dying of influenza In some cases, influenza outbreaks in nursing homes and hospitals have been attributed to low provider vaccination rates, according to the CDC. So how can you get your staff on board? Below are some strategies from the National Foundation for Infectious Diseases (NFID) to encourage your fellow A supplement to Case Management Monthly November 2013

10 case managers to protect themselves this flu season: Choose a leader. Your organization should have one person who heads the influenza vaccination initiative each year. Make it a priority. Your staff members should understand that you and the organization leaders believe vaccination is important and put it in writing. Provide education on the importance of vaccination. Pay for the vaccinations, so workers don t have to. Track compliance. Another strategy is to make getting an influenza vaccination as convenient as possible for staff members. The NFID says it s a good idea to bring the vaccine to them. Offer vaccinations in the cafeteria or during break times. The easier you make it for staff members to get vaccinated, the more likely they will be to do it. Proper hand hygiene is another important strategy when it comes to keep staff healthy this winter. The World Health Organization provides the poster below as a reminder for staff of effective hand washing technique. H CMM, PO Box 3049, Peabody, MA Telephone Fax