Case Management Monthly

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1 Case Management Monthly Best Practices and Practical Solutions March 2008 Vol. 5, No. 3 Staff satisfaction Retaining case managers starts with the right interview process After reading this article, you will be able to: 1. Identify why hiring is vital to retaining employees 2. Understand the benefits of hiring support staff 3. List three benefits case managers appreciate With so many hospitals running understaffed on a near constant basis, case managers are always in demand, and qualified case managers often feel like they can have their choice of jobs. All this makes it more difficult than ever to retain staff members and keep them happy. But case management departments can make progress toward high retention rates and become fully staffed if they operate with the right attitude and support from hospital management, says Janet Pizzelanti, MS, BA, IN THIS ISSUE p. 3 Quality care A pilot study shows the benefits of case management in physician practices. p. 5 Documentation improvement The new Medicare Severity DRG system makes complete documentation essential for facility reimbursement. p. 7 Clinical documentation improvement Physician querying is a must for accurate charting. From the Director s Desk This month s From the Director s Desk walks nurses through the process of achieving case management certification. Complex case Case managers in inpatient hospital settings must educate patients and families. RN, vice president of Healthcare Management Services at AMERIGROUP Community Care in Edison, NJ. AMERIGROUP Community Care is a nationwide health insurer that works with federal and state governments to provide care to seniors, the financially vulnerable, and people with disabilities. It all starts with the hiring process, says Pizzelanti, whose case management department is fully staffed and has a 90% retention rate. Finding a person with the I would prefer to wait for right skill set is the right candidate than to necessary, but it s hire the wrong person. more important to Janet Pizzelanti, MS, BA, RN find someone to fit in with your team, she adds. I would prefer to wait for the right candidate than to hire the wrong person. If your staff understands what you re doing, they ll be willing to wait for that spot to be filled. Setting the right tone Although no one enjoys working in understaffed departments, one advantage healthcare organizations have over other industries is that healthcare workers are caregivers first and typically care more about helping others than finding the most money they can get, says Marianne DiMola, national vice president at Pathway Medical in Kirkland, WA, and executive director of the Case Management Society of America, New York Chapter. Nurses don t have to be anywhere they don t want to be because of the nursing shortage, DiMola says. But they ll stay in one place for a long time if they believe in management and are given the proper respect. Benefits packages, salary, and bonuses are all important, but DiMola says she has seen plenty of case managers take pay cuts to go to positions where they felt like their work could be more meaningful. Case > continued on p. 2

2 Page 2 Case Management Monthly March 2008 Retaining < continued from p. 1 managers want to be appreciated for doing their jobs, she says. They are thinkers and want to contribute to the improvement of every patient they work with. One of the ways you can show case managers that their worth is valued is by hiring support staff members to handle clerical issues, freeing up case managers to focus on patients. Another way is to help them find time to focus on continual learning; balancing their lives with their careers can be difficult. On a monthly basis, we bring in a company that offers continuing education credits to our nurses, says Pizzelanti. You should also consider giving case managers a budget for going off-site to seminars and conferences, DiMola says. money out of their jobs, incentives for staying at one job are still a good way to show you value their work and loyalty, says Pizzelanti. Your staff is an investment, she says. It costs a lot of money to go out and hire someone and then re-train them. If you can put that money into your current staff, it makes for a win-win situation. Perks that may help you retain your case management staff include: Flexible hours (e.g., allowing case managers to work four 10-hour shifts frees up one day to take care of their doctor and car appointments) Referral bonuses Pizzelanti says 42% of her staff members were hired through internal referrals Organization memberships Perks still work Although case managers want a lot more than Editorial Advisory Board Case Management Monthly Hugh E. Aaron, MHA, JD, CPC, CPC-H Senior Vice President for Compliance and Regulatory Affairs/Regulatory Counsel The Greeley Company Marblehead, MA Jacqueline Birmingham, RN, BSN, MS, CMAC Vice President Curaspan, Inc. Newton, MA Wendy De Vreugd, RN, BSN, PHN, FNP Senior Director of Case Management Kindred Healthcare, West Group, Hospital Division Westminster, CA Deborah K. Hale, CCS President Administrative Consultant Service, LLC Shawnee, OK Group Publisher: Emily Sheahan Managing Editor: Andrew Thurston Laura Harrington, RN, CPHQ Practice Director of External Peer Review & Credentialing The Greeley Company Marblehead, MA Robert J. Marder, MD Practice Director of Quality and Patient Safety The Greeley Company Marblehead, MA June Stark, RN, BSN, MEd Director of Case Management Salem Hospital and North Shore Medical Center Salem, MA Karen Zander, RN, MS, CMAC, FAAN Principal and Co-owner The Center for Case Management, Inc. Natick, MA Case Management Monthly (ISSN X) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA Subscription rate: $349/year. Postmaster: Send address changes to Case Management Monthly, P.O. Box 1168, Marblehead, MA Copyright 2008 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 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or customerservice@hcpro. com. Visit our Web site at 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. MAGNET, MAGNET RECOGNITION PROGRAM, and ANCC MAGNET RECOGNITION are trademarks of the American Nurses Credentialing Center (ANCC). The products and services of HCPro, Inc., and The Greeley Company are neither sponsored nor endorsed by the ANCC. The acronym MRP is not a trademark of HCPro or its parent company. Communicating strategy The final piece of the retention puzzle is making sure your case managers feel part of the organization and that they know what is going on at every level. You should communicate management s goals and set clear expectations, Pizzelanti says. They should know what your strategic goals are and when changes are coming, she adds. Meet with your staff on a regular basis and explain to them what senior management is up to and why. Don t let them be surprised if there is some big policy change or IT switch that affects their job. Case managers want to be able to share their ideas, says DiMola. Make sure they have an avenue to do that by listening to them and understanding their needs, both on the job and off. If a case manager is experiencing a problem outside of work, you can earn their loyalty by being supportive and understanding, DiMola says. It all comes back to the Golden Rule, says Pizzelanti. You need to treat your case managers like you want to be treated by your manager. If you would expect him/ her to be flexible on an issue, be flexible with requests from your employees also. n For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at or 978/ HCPro, Inc.

3 March 2008 Case Management Monthly Page 3 Quality care Pilot study shows benefits of case management intervention for patients in physician practices After reading this article, you will be able to: 1. Identify who qualifies as a high-risk patient 2. List lessons learned from using case management with high-risk patients in a primary care physician setting 3. Understand why physician buy-in is important to case management 4. Identify barriers that prevent patients from receiving proper care The theory was that an efficient nurse case manager and an invested primary care physician (PCP) working together could have an immediate and substantial affect on the care of high-risk patients seeking care from PCPs. So in August 2004, the Massachusetts General Hospital (MGH) Revere Healthcare Center began working on a pilot study that teamed up one experienced, efficient case manager with six PCPs and roughly 120 patients identified as high-risk. The study resulted in the success organizers hoped for a widespread increase in physician, case manager, and patient satisfaction and a decrease in hospital admissions. We wanted to look at case management in a different way, says Susan Lozzi, RN, case manager at the MGH Revere Healthcare Center. Lozzi helped develop the program and served as the case manager for the project. We wanted to follow high-risk outpatients and find out where the gaps were in the care that they needed, she says. The goals of the study, all of which were reached in some capacity, were to: Improve patient/family satisfaction Improve the quality of physician professional life Improve case manager satisfaction Avoid unnecessary admissions to MGH Decrease the readmission rate Move the focus of patient management from the inpatient to the outpatient arena Improve the utilization of existing outpatient programs: disease management, call centers, community services Who is a high-risk patient? To determine the patient population for the study, Lozzi and other collaborators, including Eric Weil, MD, medical director for the CMS Demonstration Program and a PCP at MGH Revere Healthcare Center, had to decide who made up this high-risk population for whom they wanted to improve care. After discussion, high-risk patients were determined to be patients with: Multiple or complex medical problems Social issues or barriers to care High utilizers or underutilizers patients who saw PCPs too frequently or not enough for their conditions Failure to thrive Unplanned readmissions within 30 days Multiple ED or unnecessary clinic visits Adherence issues New catastrophic diagnoses High-cost/frequent hospitalizations Conditions a physician considered high-risk From there, patients were divided into three groups of risk: those at high risk and in immediate danger of failing health (50% of the population); those in stable condition but had a high probability of failure and readmission (24%); and those who were on physicians radars but had not yet failed (26%). Without this categorization, Lozzi says, it would have been nearly impossible for her to manage the caseload if all 120 patients were in the most immediate danger. The original plan was to find six physicians who could each > continued on p. 4 For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at or 978/ HCPro, Inc.

4 Page Case Management Monthly March 2008 Pilot study < continued from p. 3 choose 20 patients from these risk groups. When 14 physicians asked to participate in the project, six were chosen and the others were used as a control group. A big part of the reason physicians bought into this idea so quickly was because they had worked with [Lozzi] before and knew she was an excellent case manager, Weil says. Once the patient population was selected, Lozzi started assessing the patients. I was doing the assessments and making my recommendations, such as the need for a nurse for in-home medications, but I was not actually going to the home to administer the meds I was not the be-all, end-all, she said. But you could immediately start to see the benefits, which included patients showing up to more appointments, taking their medications more, and following plans of care more closely. Program results Lozzi attended physician visits, helped create care plans, and helped coordinate clinical and community resources, including keeping in touch with the physicians, specialists, nursing, health center staff, and patients. She did not create new resources or offer services that wouldn t have been available without her help, because the aim of the project was to see what case management could do, not what adding services could. Patients needs are tremendous, and physicians don t have time or the resources to find out why patients aren t utilizing all of what s available to them, says Lozzi. By November 2005, Lozzi had assessed all of the patients in the program and study data started rolling in. Most significantly, the data showed that there were a decreased number of inpatient admissions among the patients receiving case management. It also showed that previously, the lack of social support and nonadherence to medical regimen were found to be the biggest barriers (66% of patients) to these high-risk patients receiving the proper treatment. Analysis also showed this group of patients was in great need of mental health and psychosocial services. Another finding was that patients underutilizing healthcare were at a similar risk rate as those who were overutilizing, and that case management helped those in the underutilization population see their clinicians more often to get the help they needed. The data demonstrated that although the number of admissions decreased, the LOS for those admissions was higher. The theory remains that unnecessary admissions were avoided. PCP satisfaction Not only were the patients happy with the results, but the data also found that: 100% of PCPs strongly agreed that high-risk case management added value to PCP practice by improving coordination of care through continuum, improved quality of care for patients, and improved quality of practice life 67% of PCPs strongly agreed that working with a case manager improved the appropriateness and efficiency of office visits; the remaining PCPs agreed 67% of PCPs strongly felt they had seen an improvement in their patients ability to manage their own healthcare due to case management Following up Once the study concluded, high-risk case management didn t stop at the MGH Revere Healthcare Center. The positive outcomes from the project prompted the Massachusetts Physicians Organization and MGH to collaborate on an application to Medicare for the Care Management for High Cost Beneficiaries Demonstration Program (CMHCB). The application was successful, and the project is now one of the five national study models of care for high-cost Medicare beneficiaries that will attempt to reduce cost while improving patients quality of care. Through the CMHCB program, the pilot at the MGH Revere Healthcare Center has been expanded to 2,600 high-risk Medicare patients in 19 primary care practices in the MGH system. n For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at or 978/ HCPro, Inc.

5 March 2008 Case Management Monthly Page 5 Documentation improvement MS-DRG system makes complete documentation essential for maximum reimbursement and minimum denials After reading this article, you will be able to: 1. List the two critical pieces of the Medicare Severity DRG (MS-DRG) system 2. Identify what qualifies something as a complication/ comorbidity under the MS-DRG system 3. List conditions CMS wants documented if present on admission The idea behind CMS Medicare Severity DRG (MS- DRG) was to financially reward hospitals that treat patients with the most complex conditions. But facilities that do not understand the complexities of the MS-DRG system and are not documenting thoroughly could lose thousands of dollars once the system is fully implemented this October. We all know that one of the biggest struggles in the healthcare arena is capturing the severity of a case, said Sonya Stephens, a consultant with Sinaiko Healthcare Consulting, Inc., in Los Angeles during the January 17 HCPro, Inc., audioconference, MS-DRGs in 2008: Assess the financial impact and operationalize the rule. CMS continued the process of making severity more transparent when it implemented its Final Rule on August 1, 2007, which made the switch from the CMS- DRG classification system to the MS-DRG classification system. For case managers, the main points of interest of the MS-DRGs relate to major changes to the complication/comorbidity (CC) list and guidelines on diagnoses that are present on admission (POA). Changes The new system creates a three-tiered payment system one diagnosis, diagnosis with a CC, and diagnosis with a major CC (MCC) and the reduction in the number of CCs available to providers. CMS created 745 MS-DRGs with subgroups of CCs and MCCs. Under the old system, the CC list included the most chronic and acute conditions. But the current system includes only CCs that are significant acute disease, acute exacerbations of significant chronic diseases, advanced or endstage chronic diseases, or chronic diseases associated with extensive debility. This decreased the number of CCs from 3,326 to 2,583 and made it so that roughly 40% of patients will have at least one CC, instead of the previous percentage of 78%. To be able to bill at the higher rates the system sets up, you need patients to have CCs, Stephens said. But that will be more difficult to do with less CCs. It becomes even more difficult when you factor in the tier system, which only pays providers the maximum benefit and highest relative weight if a patient has MCCs. In > continued on p. 6 Save the date! September 24 26, Chicago HCPro, Inc., seminars Shared Governance Symposium Join us on September 24 in Chicago at the Hyatt Regency to hear practical strategies from Tim Porter-O Grady, DM, EdD, APRN, FAAN, and Kim Hitchings, RN, MSN, manager of the Center for Professional Excellence at Lehigh Valley Hospital in Allentown, PA, about building a culture to support shared governance. Nursing Leadership Summit Stay in Chicago for our Nursing Leadership Summit September 25 26, which will provide nurse leaders with proven, practical solutions to the biggest leadership and management challenges they face. To register or for more information, call 800/ or visit For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at or 978/ HCPro, Inc.

6 Page 6 Case Management Monthly March 2008 MS-DRG < continued from p. 5 many cases, having at least one CC and no MCCs pays less than the CMS-DRG system. An example of the difference in reimbursement comparing the old and new system can be seen by looking at chronic obstructive pulmonary disease (COPD). With the CMS-DRG system, COPD was DRG 88 with a relative weight of Under MS-DRG, if you were billing only for COPD, the DRG would be 192 with a relative weight of But if you add a CC, you can bill DRG 191 and receive a relative weight of By adding an MCC, you can bill DRG 190 and receive a relative weight of However, if clinicians aren t proving the CC or MCC with thorough documentation, CMS will only pay for the basic diagnosis. CMS says there isn t anything wrong with hospitals maximizing payment when they can support it through documentation, said Linda Whaley, RN, senior consultant with Sinaiko Healthcare Consulting, Inc., in Los Angeles, who also spoke at the January 17 audioconference. Case managers and other healthcare providers can be proactive in ensuring all MCCs are accurately documented by querying physicians, said Whaley. Work in the present Documentation is equally important with the other change MS-DRG presents the POA initiative. CMS wants to be able to differentiate between conditions patients have on arrival to the hospital and those they acquire during their stay. CMS already requires reporting and editing a POA indicator for every diagnosis at an inpatient acute care hospital and, beginning April 1, the agency will return for correction POA indicators. Then, beginning October 1, the following conditions will not be paid at the higher rate unless the condition was POA: Catheter-associated urinary tract infection Pressure ulcers Object left in during surgery Air embolism Delivery of ABO-incompatible blood products Vascular catheter-associated infections Mediastinitis after coronary artery bypass graft surgery Hospital-acquired injuries (e.g., fractures, dislocations, intracranial injury, crushing injury, burn, and other unspecified effects of external causes) Case managers can play a major role in ensuring that any of these POA conditions are clearly documented as such. This can be done by setting up awareness and query programs and campaigns that teach clinicians about these new rules, said Stephens. n CMM Subscriber Services Coupon q Start my subscription to CMM immediately. Your subscription will include 8 copies of CMM each month. Options: No. of issues Cost Shipping Total q Electronic 12 months $349 (CMTME) N/A q Print & Electronic 12 months of each $349 (CMTMPE) $24.00 Order online at Sales tax (see tax information below)* Be sure to enter source code N0001 at checkout! Grand total For discount bulk rates, call toll-free at 888/ *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax address (Required for electronic subscriptions) q Payment enclosed. q Please bill me. q Please bill my organization using PO # q Charge my: q AmEx q MasterCard q VISA q Discover Signature (Required for authorization) Card # Expires (Your credit card bill will reflect a charge to HCPro, the publisher of CMM.) Mail to: HCPro, P.O. Box 1168, Marblehead, MA Tel: 800/ Fax: 800/ customerservice@hcpro.com Web: For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at or 978/ HCPro, Inc.

7 March 2008 Case Management Monthly Page Clinical documentation improvement Physician querying is a must for accurate charting The best way for your hospital s documentation to be accurate is for physicians to take their time with it the first time around and to be as thorough as possible. But that often isn t the case; even when it is, case managers will often have questions about a specific patient that can only be answered by the physician. The best way to clarify these questions and to ensure your documentation will get you full reimbursement is to set up a physician query program, said Lynn Spryszak, RN, and Heather Taillon, RHIA, during the January 21 HCPro, Inc., audioconference, Clinical Documentation Improvement (CDI) Process: Best Practices for a successful program. Developing a process When creating a system for physician queries, the most important thing to do is maintain strong, open lines of communications with nurses, coders, and physicians, said Taillon, manager of coding compliance at St. Francis Hospital in Beech Grove, IN. Having a case manager who has good communication skills and is confident in clinical knowledge serve as a clinical documentation specialist (CDS) may make this process run smoother, she said. If someone has a question about a chart, he or she can contact the CDS. If the CDS is unable to answer the question or needs documentation to back it up, the CDS queries the physician. The above system should answer a lot of charting questions, but setting up a concurrent review and follow-up chart system is also an important safeguard. This type of auditing system should involve case managers pulling a set number of charts each day to review for errors or lack of documentation. The purpose of this review is to ensure you are getting credit for the highest possible Medicare Severity DRG (MS-DRG), while giving the patient the best treatment with an accurate record of the account, said Spryszak, coordinator of the clinical documentation management program at Alexian Brothers Medical Center in Elk Grove Village, IL. When reviewing charts, Spryszak said to take a look at the following items: The ER record (e.g., for past medical history, medications/treatments delivered in the ER, diagnostic tests, and paramedic reports) Nursing admission assessment (e.g., for weight/ height, skin assessment, bowel/bladder habits) Medication lists (e.g., are there medications ordered that don t have a matching diagnosis?) Resources used (e.g., is there a mismatch between resources and diagnoses?) Querying the physician When you make a query to a physician, it must not be just to obtain a higher DRG, said Taillon. Queries should be based on concurrent review of documentation for clinical results that are not done in the chart, she said. They also must be open-ended and must not lead the physician. It s the not leading part of the equation that is most difficult for some case managers, because after > continued on p. 8 Upcoming event March 27 Case management services in the ED: How to implement, refine, and evaluate your program (SKUN032708) For more information, call HCPro s customer service representatives at 800/ or visit For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at or 978/ HCPro, Inc.

8 Page 8 Case Management Monthly March 2008 Querying < continued from p. 7 their review, they know there is something the physician should have documented, but they can t just ask the physician to write in the information. That s why Spryszak has designed templates for queries to help both parties (see the Sample query tool below for an example). The query mentions the specific instance and asks for clarification on a specific part of the chart. The CDS must ask the physician to make an addendum to the record if a change is made, because queries are not part of the legal record. Physicians must document any changes in the medical record as dictation or a progress note, Taillon said. You should also have a consistent way of tracking physician queries to ensure that they are being answered, said Spryszak. At her facility, paper queries are flagged and noted in progress notes and formatted in a way physicians are used to and can t miss. If the query is a revenue-generating one, the case manager can send a fax (so it s part of the permanent record) to the physician asking for a response. Continued steps can be taken if the physician doesn t respond after that, including going to the physician advisor or the hospital upper management in the case of queries that could result in more money. Case managers might want to consider organizing charts for review as follows, Spryszak said: 1. Charts with pending queries 2. Charts without complications/comorbidities (CC) or major CCs (MCC) to check whether there should be at least one CC or MCC 3. Charts with symptom diagnoses 4. New admissions n Sample query tool ABC Hospital Network Clarification is needed for one (or more) of the following conditions in order to assign the present-on-admission indicator correctly. Please check the box that indicates whether the associated condition was present at the time of the order for inpatient admission. Y N W Yes No Unable to determine Please sign and date below: Physician signature: Date: Source: Lynne Spryszak, RN, Alexian Brothers Medical Center, Elk Grove Village, IL. Used with permission. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at or 978/ HCPro, Inc.

9 Case Management Monthly From the Director s Desk The journey toward case manager certification by June Stark, RN, BSN, MEd, director of case management at North Shore Medical Center in Salem, MA. Three years ago, I supported my RN and social worker case manager staff as they went through the process of achieving case management certification. The effort was extremely successful; 90% of the staff members became certified. Before we undertook the process, we decided to use a variety of educational strategies to meet the different learning styles of the staff members, ranging from classroom learning to individual and small group options. We first honed everyone s test-taking skills, mainly through providing an opportunity for all the case managers to answer practice exam questions. We purchased a software program containing more than 900 case management practice questions and loaded it onto each case manager s work and home computers. The process of answering multiple questions enhanced their test-taking skills and also identified each case manager s strengths and weaknesses, thus prioritizing their study time. The next step was to start classroom educational sessions and make a small resource library of relevant textbooks and articles available to the staff members. We brought in a case management consultant who offered a nationally recognized certification preparation course that was associated with a successful pass rate. As the entire case management department was preparing for the exam at the same time, we held the prep course twice and everyone had the option of attending one eight-hour session or two three-hour sessions. The classes were optional, and case managers could attend either or both of the courses. Because it was optional, case managers agreed to attend on their own time and no salary compensation was offered. The case managers were comfortable with this decision because the hospital agreed to cover all other costs of this endeavor. For the hospital, the venture was seen as an investment in the case managers. The organization covered the cost of all the educational strategies, plus the cost of each certification examination. In addition, the case managers who did not pass during the first round but had demonstrated a serious effort were offered the opportunity to take the exam again at no cost to them. The prep course was followed by a number of onehour lunchtime lectures focusing on areas requiring further explanation and review, including traumatic brain injury, workers compensation, and criteria for progression of rehabilitation. The certification exam was offered on a Saturday and those case managers already certified agreed to work that weekend to cover the staffing need. Approximately 60% of the case managers took the exam in the fall, and others took it in the spring. Ninety percent passed on the first attempt, and of those that retook the exam, 75% passed. Two case managers who did not pass decided not to try again. As the director, I learned lessons from the experience and feel it has brought many benefits: Eighty percent of the case management staff now possess certification Certification has resulted in significant knowledge growth and professional development Enhanced case management expertise has been observed in clinical practice, as evidenced by improved case manager documentation and case managers ability to handle and understand the intricacies of complex cases Case managers demonstrate increased self-esteem and pride in their achievement, resulting in an enhanced professional demeanor on the units and when collaborating with patients, families, and healthcare providers n A supplement to Case Management Monthly March 2008

10 From the Director s Desk Complex case Inpatient hospice: How do we educate patients and families? by Monica Ferraro, RN, BSN, MS Case managers in inpatient hospital settings that also include inpatient hospice programs have to accept a great deal of responsibility for educating patients and families so that they can make the right care choices. Martha is an 83-year-old resident of a skilled nursing facility (SNF). She is admitted to a local community acute care hospital for symptoms of fever, tachycardia, and shortness of breath. Martha had completed an advance directive at the SNF (including instructions to not resuscitate or intubate, and had nominated and completed a healthcare proxy). In the hospital, Martha is diagnosed with pneumonia and dehydration. She also has an extensive medical history with comorbidities of diabetes, hypertension, Parkinson s disease, and intracranial hemorrhage. The dehydration and pneumonia are immediately treated, but Martha remains lethargic and unable to swallow, continuing to require naso-gastric feedings. Martha s daughter is her healthcare proxy, and because of Martha s continued failure, her daughter is asked to make a decision to allow surgeons to place a permanent feeding tube. The daughter instead decides to allow her mother to be made as comfortable as possible by being placed in the inpatient hospice program. An informational meeting is arranged with a hospice nurse, and Martha s daughter signs her mother into the hospice benefit available through Medicare. The next day, following consultation with other family members, Martha s daughter decides to revoke the hospice benefit and she starts to reconsider giving Martha a feeding tube. A case manager discusses with the daughter Martha s options for placement in an SNF after the feeding tube has been placed. Meanwhile, the case manager has discovered Martha does not have long-term care insurance and does not qualify for Medicaid. She only has Medicare and a commercial secondary product. Her daughter cannot find paperwork to account for the distribution of her mother s assets from the sale of her mother s home several years ago, so Martha had been denied Medicaid coverage. The case manager is concerned about Martha s need for long-term care and lack of insurance to cover the expenses. Twelve days have elapsed since Martha s admission, and her daughter has now changed her mind again and wants to cancel the feeding tube and reconsider enrolling Martha into the inpatient hospice benefit. Martha is eventually discharged to a SNF, without a feeding tube, for comfort care after a 14-day LOS. After Martha leaves the hospital, the case managers and social workers conduct a retrospective case study to determine what may have been done differently. After review, the case managers and social workers decide that explanation about hospice could have been better or more detailed to help the daughter understand. They realize that patients family members are often asked to make many difficult decisions at a time when the stress in their lives is intense. In retrospect, they realize that if Martha s advance directive had been more specific (including instructions about feeding tubes), then the decisions would have been less complicated for Martha s daughter. Martha s case highlights how case managers must take the time to educate patients and families about advance directives and the need for people to be specific about their wishes for end-of-life care. n CMM, P.O. Box 1168, Marblehead, MA Telephone 781/ Fax 781/

11 Continuing 1. With the elimination of the a. be responsible for the accur b. have the administrator c. have the coder sign the d. have the PRO check 2. What is the first a. books b. consulting time new CPT books CMM Continuing Education Quiz January March 2008 A service of CMM Accreditation statement: HCPro is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation. Credit designation statement: This educational activity for three nursing contact hours is provided by HCPro, Inc. Directions: Fill out your contact information in the space provided. Complete the exam by circling the letter that corresponds to the correct choice for each question. The questions are based directly on content from the January March issues of CMM, and you may refer to them as you take the exam. Return the exam to us by April 15, To qualify for three nursing contact hours/six case management continuing education (CE) credits, you must answer at least 80% of the questions correctly that s 24 correct answers out of the 30 questions. Upon successful completion of the exam, we ll you a certificate that you may use for display and documentation of three CE credits toward your nursing certification/six CE credits toward your case management certification. Name: Facility: Address (city, state, ZIP): Nursing license number: Telephone: Fax: January When is it a key time for case managers to advocate for the best interests of their patients? a. When the cases are extremely complicated b. Whenever a case manager has a light caseload c. When a case manager is new on the job d. When the patient threatens to file a formal complaint 2. Long-term acute care (LTAC) hospitals are recommended for what type of patient? a. Any elderly patient b. Any infant c. A patient who is prone to filing complaints against healthcare facilities d. A patient who requires ongoing complex medical care 3. Why is it a challenge to provide care to patients in short-term acute care (STAC) facilities? a. Patients do not want to stay in short-term facilities b. They require a longer LOS than allotted by the facilities c. Federal reimbursement of care is limited d. Short-term facilities often experience staffing shortages 4. Why are the skills for case managers at LTAC facilities required to be more complex than at STACs? a. LTAC case managers work longer hours b. LTAC case managers have a caseload of extremely complex and serious cases c. LTAC case managers have more work experience d. LTAC case managers always work with the elderly A supplement to Case Management Monthly

12 5. What is unique about Kindred Healthcare s approach to care for patients with multisystem failure? a. It has no STAC hospitals within the organization b. The LTAC hospitals and pulmonary units feature an interdisciplinary environment c. The nurses and physicians demonstrate a better ability to communicate than seen in most facilities d. It s management style is not outcomes oriented 6. Why is it beneficial to improve your time management skills? a. You will make more money b. It will directly improve patient satisfaction c. It will lower your stress level d. You have a better chance of a promotion 7. How does Heather Grondin, RN, recommend you approach a potential conflict? a. Make sure to include several other people in the confrontation b. Talk to the person immediately c. Prepare a script before the confrontation d. Know what you want to get out of the confrontation 8. According to Diana Lang, multiple studies have shown that oxygenation of the body calms the stress response. Which of the following is NOT a benefit of breathing exercises? a. Relaxed heart rate b. Lowered blood pressure c. Better digestion d. Calmer mood 9. How does Joan Monchak Lorenz, MSN, APRN, BC, recommend improving the general health of the workplace? a. Increasing salaries b. Adding job benefits c. Instituting social events d. Creating communication ground rules 10. Regular exercise is obviously beneficial to one s health. What is a less obvious benefit of exercise during the workday? a. Helps to redirect one s focus b. Prevents headaches c. Makes up for lost sleep d. Helps one s ability to communicate February The advanced practice nursing (APN) program with a disease management component was funded by what organization? a. The Case Management Society of America b. The National Institute of Nursing Research c. The American Case Management Association d. The Robert Wood Johnson Foundation 2. What was the goal of the study performed at Case Western Reserve University? a. To determine whether the high costs of care and poor outcomes for patients who require prolonged hospitals stays could be reduced by a posthospital disease management program b. To reduce LOS through the use of a new electronic database c. To create a disease management program for uninsured patients d. To reevaluate current discharge planning programs in order to standardize a nationwide reduction in current patient LOS 3. The study found that the benefit to establishing an advanced practice nursing program with a disease management component for chronically, critically ill patients is a reduction in. a. critically ill patients b. overall average patient LOS c. overall hospital costs d. the number of readmission days for those patients readmitted to the hospital 4. The study found the disease management program resulted in an average of fewer hospital days per patient following hospital readmission. a. 2.5 b c. 3.4 d How many intensive care patients did the study include? a. 500 b. 355 c. 335 d. 150 Page 2 Case Management Monthly Continuing Education Quiz January March 2008

13 6. APNs involved with the program provided an intervention that focused on what particular areas? a. Case management and LOS b. Case management and interdisciplinary communication c. Communication and discharge planning d. Communication and reduction of hospital costs 7. Why were some physicians and facilities not accepting of the APNs assistance in the patients care? a. Facilities did not have enough money to support the program b. Physicians do not respect APNs c. Facilities felt the program was too time-consuming d. Physicians did not communicate well with the APNs 8. What is the purpose of the Surrogate Health Care Act of Illinois? a. To prevent family members from signing a do-not-resuscitate (DNR) order for an incapacitated patient b. To provide monetary assistance to patients who are unable to make their own healthcare decisions c. To establish who signs a DNR order for an incapacitated patient d. To identify an order of preference for the people who can make healthcare decisions when a person lacks the ability to do it 9. When was the Illinois Health Care Surrogate Act signed into law? a b c d When was the Uniform Health Care Decision Act a hybrid law intended to replace the fragmented and often-conflicting laws in the states approved into law? a b c d March Why does your hiring process play a major role in retaining case managers? a. Case managers never stay in place for long periods of time, so you can t retain, you can only rehire b. By hiring case managers that fit your team philosophy, there is a better chance they ll remain happy c. If you don t offer the highest salary during the hiring process, case managers will always be on the lookout for a better-paying position d. Case manager candidates like to interview all potential coworkers prior to management making a decision 2. Which of the following is not a benefit of hiring support staff members for your case managers? a. Support staff members free up time for case managers to work with patients b. Support staff members do a lot of the work case managers don t like to do c. Support staff members are able to obtain a patient s medical history d. Support staff members don t affect the budget as much as a case manager 3. Which of the following benefit packages helps retain case managers while being beneficial to your facility? a. Offering continuing education classes or reimbursement and referral bonuses b. Stock options and 401(k) plans c. Insurance and company parties d. Case managers aren t interested in benefits 4. In the Massachusetts General Hospital (MGH) Revere Healthcare Center study, which of the following types of patients did not qualify as a high-risk patient? a. Patients with multiple/complex medical issues b. Patients with adherence issues c. Children d. Patients with multiple ER visits 5. Which of the following did the MGH Revere Healthcare Center study discover? a. Case management has little effect on patients in a primary care setting b. Intensive case management improves patient and physician satisfaction c. Physicians need access to new resources in order for patients to get the care they need d. Physicians don t like having case managers present during patient visits 6. Why is physician buy-in an important part of adding case management to a primary care physician practice? a. Case managers and physicians will have to communicate well for the program to work b. Physicians pay the case managers salaries c. Case managers will make the physicians jobs more difficult d. Physicians will have to spend time training case managers Case Management Monthly Continuing Education Quiz January March 2008 Page 3

14 7. Which of the following is a common barrier for patients receiving proper care? a. Physicians not having proper medical histories b. Patients not trusting their doctors and nurses c. Pharmacists don t explain to patients how to use their medications d. Patients don t have the social support to sustain their medical regimens 8. What is one critical piece of the Medicare Severity DRG (MS-DRG) classification system for case managers? a. Hospitals will now be receiving a lot more money b. The list of complications/comorbidities is different now c. CPT codes no longer matter d. Nurses can now document severity if the physician doesn t 9. What qualified something as a complication/comorbidity under the new MS-DRG system? a. All chronic diseases qualify b. The list is the same as the CMS-DRG list c. All ICD-9 codes are on the list d. Significant acute diseases qualify 10. Which of the following conditions does CMS not require you to list if it is present on admission? a. Object left in during surgery b. Catheter-associated urinary tract infection c. Cancer d. Pressure ulcers Evaluation 1. Did this CE activity relate to its stated learning objectives? 2. Was the format of this CE activity easy to use? 3. Did we avoid commercial bias in the presentation of our content? 4. Will this activity enhance your professional development? 5. How long did it take you to complete this activity (including reading, taking the exam, and completing the evaluation)? HCPro, Inc., is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. The CMM editorial advisory board has signed a vested interest form declaring no commercial/ financial stake in this activity. If you have any questions or concerns, please contact our customer service department at 800/ Fax or mail your exam and evaluation by April 15, 2008, to Case Management Monthly CE exam, P.O. Box 1168, Marblehead, MA 01945, fax: 781/ , attn: Kerry Betsold, CE manager. Page 4 Case Management Monthly Continuing Education Quiz January March 2008