Case Management Monthly

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1 Best practices and practical solutions Case Management Monthly P5 P6 P8 CMS discharge planning checklist Use this checklist excerpt to help patients track important follow-up items prior to leaving the facility. Observation vs. inpatient Get tips on determining how to properly assign patients to observation or inpatient services. Possible changes for inpatient definition An expected CMS final rule could change the definition of an inpatient. From the Director s Desk Addressing the problem of failure to include discharge notes in the record. Volume 10 Issue No. 9 september 2013 Complex case Learn how a case manager dealt with a heart failure patient who was continually readmitted for treatment. Practical suggestions to help you implement CMS discharge recommendations Learning objectives: Describe practical solutions to help organizations get started on implementing new CMS discharge recommendations Identify best practices for creating discharge plans for all patients Evaluate the benefit of forming partnerships with postacute facilities Identify strategies for creating abbreviated discharge plans Last month, CMM told you about a recent set of revisions to the discharge planning section of the CMS State Operations Manual. Although most of the changes amounted to housekeeping, CMS did take the unusual step of including some non-binding best practice recommendations related to discharge practices. Surveyors won t penalize your organization if you don t follow them, but experts say organizations should take note of these recommendations and consider heeding them whenever possible. To help you do just that, we asked our experts for some practical suggestions for each of the CMS best practice areas to get you started on the right foot. This month, we ll tackle a portion of the list, and next month we ll look at the additional CMS recommendations. Use a shortened discharge process. CMS says hospitals should Trendspotting 5% Cases of hospitals improperly assigning patients to outpatient observation increased 5% between 2006 and $4 billion The Comprehensive Error Rate Testing report for 2012 found that 36% of one-day stays were determined to be improper inpatient admissions costing more than $4 billion. $112,000 Failure to document when a patient with dangerously low sodium levels left against medical advice cost a hospital $112,000 after the patient was readmitted later with serious complications.

2 Case Management Monthly September 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 Report offers steps to reduce heart failure readmissions A study published in Circulation: Cardiovascular Quality and Outcomes unveiled steps for hospitals to prevent heart failure patients from being readmitted within 30 days of discharge. Researchers found that readmissions could drop as much as 2% if all six recommendations are followed. The steps include forming partnerships with community doctors, collaborating with other hospitals, and having nurses supervise medication plans. Discharge data provides insight into errors Drexel University School of Public Health researchers found that discharge data can help hospitals track medical errors. Researchers analyzed discharge data in Pennsylvania during one year, comparing hospital stays with and without medical errors. The study found that 9% of hospital discharges in Pennsylvania in 2006 were for stays with a medical error; errors added an average of $35,000 to the cost of care and three days to LOS. 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 A patient who is stable [and] has a capable, available, and willing caregiver still needs at a minimum a follow-up doctor s appointment. Jackie Birmingham, RN, MS I have found that if you don t keep your eye on the ball with observation, things will get completely out of control no matter how firmly established you thought your process might be. Deborah K. Hale, CCS, CCDS 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 serv ice 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 September 2013 Case Management Monthly consider using an abbreviated post-hospital planning process for certain patients. This might include some outpatients, such as those who underwent sameday surgery and were discharged from observation services. However, Jackie Birmingham, RN, MS, nurse educator and consultant from Suffield, Conn., says that hospitals should follow specific processes for all patients, regardless of whether their diagnoses are complex. For example, create a checklist of to-do items. This checklist should ensure that: The patient has clothes to wear home (especially in the winter or if the patient is admitted through the ED). The chart includes a written discharge order. The patient has transportation. The patient knows how to make follow-up appointments (note the patient s doctor, the doctor s phone number, contact information for a visiting nurse association if applicable, and physical/ occupational/respiratory therapy information) The patient understands what prescriptions should be filled on the way home. The patient has written self-care instructions. Language interpretation services are available if needed. The record includes family phone numbers for discharge, including cell phone and information on how to get medical information to the next provider. The patient s residence is accessible and safe. Are there steps? Is the door locked? Does the patient have a key? The patient has access to meals at home. Can someone purchase the meals? How will they be provided? Who will prepare the meals? Who will serve them and clean up afterward? Arrangements have been made with social service agencies, such as Medicaid, a church, or an area agency on aging, to provide any support services that may be needed. Also be certain to list any important health-related messages for the patient. Make discharge planning a collaborative process. CMS says you should consult your hospital s medical staff and other disciplines such as physical therapy when creating discharge planning policies and procedures. Additionally, be sure to include representatives from other healthcare facilities and professionals that provide postacute care for patients, such as long-term care facilities, rehabilitation facilities, nursing homes, and physicians. Patients and patient advocacy groups should also participate in the discussion. It s wise to do your discharge planning rounds early in the day and choose your clinicians based on the patient s service line, says Birmingham. For example, in the stroke unit you might consider involving clinicians from occupational therapy and physical therapy. Bring physicians and nursing unit staff into the loop and ensure the discharge plans are discussed. Create a place for the team to document assessments, their plans, and what the patient intends to do for follow-up. Document refusals. If a patient is reluctant to participate in the discharge planning process or follow discharge- related recommendations, it s important to investigate and document, according to CMS. If a patient needs discharge planning to avoid a potential adverse event or readmission and he or she refuses to participate, it s important to get the patient s physician, family, and/or other responsible caregivers involved in the discussion, says Birmingham. You may need an interpreter to assure that a patient with LEP [limited English proficiency] understands the risks of not having a discharge plan such as a referral for home health, she says. A social worker should get involved for situations in which refusing the discharge plan puts the patient at risk, and the patient s reasons for refusal aren t clear. Review your policy for patients who leave against medical advice. Keep in mind that if a patient decides to leave against medical advice, it may be costly for the hospital, says Glenn Krauss, a senior manager at Accretive Health in Chicago. In one instance, a patient with dangerously low sodium levels left a hospital against medical advice and wasn t asked to sign a form stating that he had been informed of the related risks 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 September 2013 He was later readmitted with serious complications, and because the hospital did not have the appropriate documentation, it had to foot the bill to the tune of $112,000 for the return stay when insurance denied coverage. Create discharge plans for all patients. CMS advises that hospitals create discharge plans for all inpatients to reduce the risk that a patient will have an adverse event after he or she leaves the hospital. This doesn t mean that every discharge plan should be the same, though; some plans will be more complex than others. Nurses should take the helm when it comes to most plans, according to CMS, but case managers should get involved with complex cases. Case managers should also get involved when a patient has been readmitted or has other high-risk characteristics, which can be determined by using a screening tool, according to Birmingham. A patient who is stable [and] has a capable, available, and willing caregiver still needs at a minimum a follow-up doctor s appointment, says Birmingham. This appointment should ideally be made within seven days of discharge. All patients also need written instructions on how to care for themselves after discharge, as well as directions on what they should do in response to specific symptoms such as operative-site swelling or weight gain. Implement the teach-back method when providing discharge instructions. This method asks the patient to repeat back information that has been given to make sure he or she understands it clearly, says Birmingham. Form partnerships with postacute facilities. According to CMS, care transitions can be improved if hospitals start to forge stronger ties with postacute care facilities. You don t necessarily have to have a formal agreement to forge a partnership, notes Birmingham. It means talking to postacute care facilities about the discharge process not just making a referral for an individual patient, she says. Some strategies for creating better relationships are as follows: Invite postacute providers to staff meetings to help hospital staff understand what happens to patients following discharge. Choose a level of care and become educated about that level s admission rules. Learn what services are provided at that level of care, how long the patient is expected to remain at that level, and what will happen to the patient after discharge. Document accurately to follow postacute rules for reimbursement. What does a postacute facility need to do to ensure reimbursement and remain in business? It s a good idea to start the partnership process by looking at your most frequent type of referral source. For instance, you might get a majority of your referrals from a home health agency, a skilled nursing facility, or an inpatient rehabilitation facility. Be certain to provide education to facilities in a professional manner. You don t need to provide lunch at these meetings, just education, says Birmingham. Lunch-and-learn meetings should be cleared with your administration and should follow the hospital vendor policy, she says. Also, remember to follow HIPAA regulations. Do not talk about or mention names of specific patients, Birmingham says. If there is, or has been a specific patient issue, that should be handled privately and with only individuals who need to be involved. Consider establishing scheduled times for each type of postacute facility representative perhaps monthly, or twice a month. Or, you could just set aside 30 minutes with staff during your staff meeting and record the discussion in the minutes. Some hospitals offer vendor fairs in conjunction with an educational event where a variety of postacute facilities come to one session. This can work, but a 30-minute focused session where specifics are discussed is also helpful, says Birmingham. Ultimately, there are different ways your facility can ap proach incorporating the new CMS discharge recommendations. Take the time to evaluate where your facility stands and consider the different options before you begin the process. H 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 September 2013 Case Management Monthly Use a discharge planning checklist When working on discharge planning with patients, it can be helpful to provide them with tools they can use to track their own care. CMS created this discharge planning checklist for patients to help them track important items that they need to follow up on prior to leaving a hospital or nursing home. We re including a portion of the checklist, but you can visit pdf/11376.pdf to see the rest. ACTION ITEMS What s Ahead? Ask where you will get care after discharge. Do you have options (like home health care)? Be sure you tell the staff what you prefer. If a caregiver will be helping you after discharge, write down their name and phone number. Your Health Ask the staff about your health condition and what you can do to help yourself get better. Ask about problems to watch for and what to do about them. Write down a name and phone number to call if you have problems. Use My Drug List to write down your prescription drugs, over-the-counter drugs, vitamins, and herbal supplements. Review the list with the staff. Tell the staff what drugs, vitamins, or supplements you took before you were admitted. Ask if you should still take these after you leave. Write down a name and phone number to call if you have questions. Recovery and Support Ask if you will need medical equipment (like a walker). Who will arrange for this? Write down where to call if you have questions about equipment. Ask if you re ready to do the activities listed below. Circle the ones you need help with and tell the staff. Bathing, dressing, using the bathroom, climbing stairs Cooking, food shopping, house cleaning, paying bills Getting to doctors appointments, picking up prescription drugs Make sure you have support (like a caregiver) in place that can help you. See Resources for more information. Ask the staff to show you and your caregiver any other tasks that require special skills (like changing a bandage or giving a shot). Then, show them you can do these tasks. Write down a name and phone number to call if you need help. Ask to speak to a social worker if you re concerned about how you and your family are coping with your illness. Write down information about support groups and other resources. Talk to a social worker or your health plan if you have questions about what your insurance will cover and how much you will have to pay. Ask about possible ways to get help with your costs. Ask for written discharge instructions (that you can read and understand) and a summary of your current health status. Bring this information and your completed My Drug List to your follow-up appointments. Use My Appointments to write down any appointments and tests you will need in the next several weeks. For the Caregiver Do you have any questions about the items on this checklist or on the discharge instructions? Write them down and discuss them with the staff. Can you give the patient the help he or she needs? What tasks do you need help with? Do you need any education or training? Talk to the staff about getting the help you need before discharge. Write down a name and phone number to call if you have questions. Get prescriptions and any special diet instructions early, so you won t have to make extra trips after discharge. Source: CMS 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 September 2013 Tips and tricks for navigating the observation vs. inpatient conundrum Learning objectives: List the latest updates related to assigning a patient to inpatient or observation services Identify challenges to accurate patient assignments and best practices for overcoming those challenges Observation or inpatient? It sounds like a simple question, but it continues to be a sticky area for most facilities. If your organization is having trouble correctly assigning every patient, you re not alone. Who would have ever thought that use of observation services would be such a controversial discussion topic today, but certainly the controversy is growing, said Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, Okla. Hale spoke on the recent HCPro audio conference Observation Services 2013: Establishing Key Performance Indicators. Since 2010, CMS has been concerned that hospitals are improperly assigning patients to outpatient observation, said Hale. The percentage of these cases has gone up 5% between 2006 and 2011, and CMS is increasingly receiving complaints from beneficiaries. Patients who receive observation services have to pay for self-administered drugs that are not covered under Part B as well as coinsurance amounts for diagnostic and therapeutic services ordered. They may also have to foot the bill for skilled nursing benefits, because they don t have the required three-day qualifying hospital stay. However, while there has been much attention paid to the overuse of observation services, other data shows the opposite problem. In that CERT [Comprehensive Error Rate Testing] report for 2012, they did find that 36% of the one-day stays were determined to be improper inpatient admissions to the tune of a little over $4 billion, said Hale. With this in mind, it s no surprise that hospitals are feeling some irritation over this issue. I don t even think confused is the word anymore, just frustrated about what Medicare expects us to do and how even though we follow those instructions as we understand them, we often see the need to appeal and appeal and appeal, says Hale. The good news is that 77% of appeals are successful. As of presstime, CMS was mulling some proposed revisions to the definition of an inpatient that some hope will clarify these issues. (See related story on p. 8.) In the meantime, it can be a tough call deciding whether a patient needs an inpatient admission, said Hale. And what happens when they only stay one or perhaps two days, and then what happens when we don t admit them and they end up staying two, three, four, five, six days? Making the right call Hospitals need to establish the proper front door management techniques to help physicians determine the most appropriate level of care, said Hale. Below are some tips and clarifications to help get you on the right track: Take a step back. Look at your observation program from the point of registration, said Hale. Look at all the things that are going right or not as well as you d like for them to, and follow it all the way through to the claim and the remittance advice to see whether or not you re being paid correctly. And more often than not, you will find that you re either leaving money on the table or you re being overpaid because you didn t correctly bill some things. It s always surprising to see how it turns out, she said. Educate your physicians. The best way to ensure proper billing and assignment of patients is through physician education, said Hale. This education is critical to make sure that patients are assigned to the right level of care from the very beginning, she said. So many times we ve, actually as hospitals, I think encouraged the physicians to say, Oh, doc, don t worry about it. We ll figure it out and we ll let you know which is best, observation or inpatient, said Hale. And certainly the physicians have jumped on that bandwagon in many hospitals and said, Look, I m not a biller. This is a billing issue. But actually, it s not a billing issue it s a clinical decision that must be made by a physician, according to the Medicare Benefit Policy Manual. Help physicians understand how important this decision is, for patients and their access to benefits as 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 September 2013 Case Management Monthly well as hospital compliance. Give physicians feedback when they ve done a good job and they re beginning to improve their ability to choose between inpatient and outpatient. Positive feedback goes a lot further than the negative, said Hale. But for physicians who aren t getting it right, there must be some accountability from the utilization review committee. There should also be some discussion and counseling if they consistently make incorrect decisions despite receiving assistance from the case management department. Assess your risk. So if we re going to get this right, we realize today that we just absolutely have to manage this from the doors of the organization. Every hospital s doors are a little different, said Hale. Every hospital s needs are different, and they should certainly assess their risk based upon that point of entry and decide where they need to man the doors, if not all of them, which ones are the most important to help the physician determine the most appropriate level of care. Then leave it to the physician to make the final decision. Establish a solid audit program. Use audits to take a look at the percentage of current observation patients by payer, and then audit to determine whether the decision-making behind each patient case is appropriate. If it is, the percentage you re reporting right now may be exactly where you need to be. If so, make that percentage a key performance indicator and measure it every month to ensure that it stays the same. I have found that if you don t keep your eye on the ball with observation, things will get completely out of control no matter how firmly established you thought your process might be, said Hale. So just look for any change that s not explained by a change in Medicare rules or a change in the types of services provided. Look at conversions. Another volume indicator that can show whether your process is in control is how many observation patients, or what percentage of your observation discharges, are converted to inpatient as you move along. Also, look at the number of hours billed for each claim. You know, so many times we look at a claim and we ll look at the number of units of service billed under revenue code 762, said Hale. We look at the from and through dates on the claim, and you can tell that the patient was in the hospital exactly 24 hours and we have a total of 24 hours billed for observation services. It s unlikely all 24 hours are billable. Ask what else is being included, such as time after the patient has completed observation care, time spent waiting for a ride home, or time spent making placement arrangements. Those are not billable observation hours. And so we really need to look at the average number of billable units per claim versus the average from and through dates and just see what percentage of the time is actually billable as observation stay, said Hale. Examine LOS. Also be sure to audit for LOS greater than 48 hours or less than eight hours. And certainly the reason for that would be that you may be just trying to cut off the last couple of hours of your emergency department visit to meet your four-hour throughput goal, said Hale. If your review turns up a lot of observation stays that are two or three hours long, it may indicate that observation is being used inappropriately to manage ED time. Taking the time to focus on this issue will help you spot troublesome trends or patterns in your observation versus inpatient cases and make the necessary changes to get back on track. H Continuing education information 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., July, August, and September 2013) Successfully complete and submit the quiz offered in the September issue (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 continuing nursing education 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 7

8 Case Management Monthly September 2013 Inpatient definition may change under proposed rule Learning objectives: Discuss the relationship of physician orders to determination of patient status Describe potential changes to the CMS definition of inpatient status As of presstime, CMS had still not issued an anticipated final rule that could change the definition of an inpatient, potentially clarifying the question of inpatient vs. outpatient observation assignment for patients. The proposed revision was slated to be included as part of the agency s proposed inpatient prospective payment system (IPPS) rule for the 2014 fiscal year. Discussion on this topic began last November, said Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, Okla., who spoke at the recent HCPro audio conference Observation Services 2013: Establishing Key Performance Indicators. The thinking from CMS was that maybe the definition of an inpatient admission should be changed so that hospitals could be more clear about when such an admission is appropriate, said Hale. CMS also invited comments from providers. But when they did publish the final rule [for 2013], they didn t come to a solution as to what the change should be, so we see it carried over into the inpatient prospective payment system s proposed rules for 2014, said Hale. The following is a rundown of some of the proposed changes that may be included in the final rule, which was expected to be released sometime in August. The physician order CMS has placed a significant amount of focus on the physician order, which determines patient status. CMS stresses that it s important for the physician to use the correct wording when writing the order; namely, the agency has determined that admit indicates inpatient status, so physicians should not use the word admit when referring to patients assigned to observation services. Without an order, a hospital does not have a billable claim. The new rule would clarify who can take responsibility for an order other than a physician, said Hale. Currently, some hospitals allow the physician to delegate this responsibility to a case manager or ED physician, provided state law or bylaws allow it. But the proposed rule does not allow this only the physician may take responsibility for the order. Under the proposed rule, physicians can still use a variety of order types, including verbal, telephone, pre-printed, electronic orders, or protocols. However, verbal orders must be signed promptly by the provider, said Hale. It may be left up to facilities to define the word promptly. The proposed rule also makes it clear that a physician s order for inpatient admission is not the final word. [CMS does] not presume medical necessity of that admission just because the physician has ordered admission, said Hale. Even if a physician takes full responsibility for an inpatient assignment, it s not enough. There also must be objective evidence in the medical record to support the decision. This information must be complete enough to allow an outside auditor to confirm that the admission was medically necessary. In the proposed rule, it appears CMS will take the step of requiring a certification statement for an inpatient admission, said Hale. Changing definition for inpatient admission CMS is also proposing a major change for the definition of an inpatient admission. The concept is moving away from the 24-hour benchmark that has long been the standard for differentiating between an inpatient level of care and an outpatient level of care and transitioning that to two utilization review midnights, said Hale. What this means for physicians is that they should not only consider the severity of the patient s condition and his or her risk of complications, but also whether he or she will require two midnights in the hospital rather than 24 hours, said Hale. And any patient that they expect to require less than two midnights should be managed in the outpatient setting, said Hale. H 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 Case Management Monthly From the Director s Desk Put those discharge notes in the record by Glenn Krauss In my job as a clinical documentation improvement specialist, I see a lot of patient charts. There is one problem I see on a regular basis: a lack of discharge notes in the record. Sometimes a note will be included that says see dictation. The problem is that dictation is not readily available when a patient is discharged, meaning the patient is leaving the hospital without this summary in place. The discharge summary and additional information are supposed to be available before a patient leaves the hospital and is scheduled for follow-up. What s the big deal about not having a discharge summary? For one, it makes it impossible for the doctor to bill an evaluation and management service for that day. Billing regulations for evaluation and management require that a patient assessment be conducted by the clinician. This must include an exchange of clinically reasonable and necessary information, and this information must be used to clinically manage the patient. There must be unequivocal evidence in the record that the clinician evaluated the patient and utilized his or her clinical judgment and medical decisionmaking to determine that the patient was clinically stable for discharge. One billing requirement is that the doctor sees and evaluates the patient on the day of discharge. But if there is no physician note, either handwritten or dictated, on the day of discharge, there s no evidence that the doctor has seen that patient, and he or she can t get paid. Having a discharge note in the record demonstrates that the doctor evaluated and assessed the patient and made a conscious decision to discharge the patient based upon his or her evaluation and clinical judgment. This discharge note should include the final discharge diagnoses. It should also represent all the clinically relevant health conditions that the physician actively managed during the patient s hospitalization and include general plans for postacute care. A missing discharge summary may also compromise the quality of aftercare, because it means that the nursing home or SNF that accepts this patient after discharge may not have clinically accurate and complete patient care instructions to follow. At most organizations, there is likely room for process improvement when it comes to the quality, timeliness, and availability of discharge summaries. It s not enough to have a medical record policy that calls on physicians to fix deficiencies in the medical record within 30 days. Policies must support the basic intent of the discharge summary that it provides a summary of patient care and hospitalization and outline postacute care plans. If the proper discharge instructions aren t in place, the patient may be discharged before he or she is stable and ready or a third-party reviewer may get the impression that an unstable patient was discharged, raising quality of care issues. Case managers should make sure that an effective, clinically succinct discharge note and summary is always part of the medical record and that it is completed on time. Doing so allows healthcare professionals to double check on whether the discharge plan is still valid for that patient. A discharge plan also gives patients clear instructions that they can take home, reducing the chances that they will fail to follow discharge instructions and wind up back in the hospital. Finally, a strong discharge summary allows case managers to ensure proper follow-up for the patient. They can ask critical questions such as whether anyone followed up to make sure the patient has an appointment with the doctor. Ultimately, making sure that the discharge summary isn t neglected is an important part of ensuring both quality care and accurate billing. Take the time to make sure that it s not missed, that it is dictated in a timely fashion, and most importantly that it meets the required standard elements as promulgated by The Joint Commission and National Quality Forum Safe Practices for Better Healthcare (2010 update). H Editor s note Krauss is senior manager at Accretive Health in Chicago. He may be reached at GKrauss@Accretivehealth.com. A supplement to Case Management Monthly September 2013

10 Complex Case Case study: Heart failure frequent flyer The first time George, a patient with congestive heart failure, is admitted, his case manager Janet closely follows his progress. Janet knows that for patients with a chronic disease, their first hospitalization admission is pivotal it means that their disease has progressed to a new level of severity requiring heightened medical and nursing care to stabilize. At this critical point, Janet believes that if she implements a comprehensive, thoughtful transitional plan, she can prevent George from being readmitted. Working closely with the cardiology unit nursing staff, Janet and the unit nurses develop an educational plan to teach George about his diagnosis, as well as a treatment plan including his prescribed diet, medications, and activity. In addition, Janet provides George with a scale to obtain daily weights and a notebook for him to record his results, along with his blood pressure reading and pulse rate. She makes sure that George demonstrates his technique for measuring his weight and vital signs to the staff nurses. He seems to be engaged in the process. Next, Janet makes arrangements for George s wife, Nancy, to participate in the education process. Nancy listens intently to each educational session and appears committed to her husband and his health. The staff nurses supplement the oral teaching with many different kinds of reading materials, including booklets, refrigerator magnets, posters, and medication administration charts. The goal of the reading material is to reinforce all the new information that Nancy is receiving. Janet finalizes the discharge plan by enrolling George in a homecare heart failure telemonitoring program. At this point, Janet feels satisfied that her plan will successfully transition the patient to home. Three days later, to Janet s surprise, George is readmitted for noncompliance with his diet and medications. Once treated and stabilized, the patient/family education is initiated again. However, immediately prior to this, Janet and the cardiology nursing staff meet to evaluate the educational processes that had occurred on the first admission. They reach the conclusion that George s patient education could perhaps benefit from the teach-back method, which has gained national attention as a positive methodology for readmission avoidance. Its major focus is to create a safe learning environment that allows the patient and family to demonstrate the knowledge and skills taught to them. The teach-back sessions are delivered, and as a final step, Janet has the patient s homecare nurse present at discharge to carry out a warm discharge. During the warm discharge, Janet and the homecare nurse discuss all the elements of care and the educational plan that has been provided for George and his wife. Despite the care team s efforts, though, George continues to be frequently readmitted. Janet is frustrated, but doesn t want to give up. She seeks out support from the director of quality, who directs her to the Ask Me 3 method. Janet goes online and learns that the focus of this method is to teach the patient and family the three main healthcare issues that will lead to their success at home. Janet and the nursing staff determine that knowledge of the patient s diagnosis, daily weights/diet, and medication regimen would be the three areas of focus. Using this plan, new teaching is initiated and reading material is again provided to supplement the process. Reinforcing the care continuum, the homecare nurse is included in this new teaching approach. When George continues to be readmitted despite all these elaborate plans, Janet decides that some patients may not fit the mold described by best case management practices. She thinks that there must be exceptions, and that George is definitely one of them. Even more alarming is that George s physical condition is deteriorating. Janet perseveres, and on one of George s last readmissions, she makes the discovery that Nancy cannot read. Critically, this leaves her unable to use the supplemental printed material to provide reinforcement of care at home. Janet does not know how this fact has been missed by everyone involved in this case, but the situation makes her realize how important literacy is, both for this case and for future patient/family assessments. Now that the literacy issue has been identified, the appropriate interventions are implemented, and George is able to leave the hospital for good. H CMM, PO Box 3049, Peabody, MA Telephone Fax

11 P.O. Box 3049 Peabody, MA tel fax url Continuing education information The quarterly continuing education quiz for Case Management Monthly is now online! To obtain your nursing and/or case management continuing education credits, you must successfully complete the online continuing education quiz by going to: A certificate will be ed to you immediately following your successful completion of the quiz. Please note: The expiration date for this activity is September 1, You must complete your online quiz by this date to receive continuing education credits. If you have questions regarding this product or activity, please contact HCPro s customer service department at 877/ for further assistance. Nursing Contact Hours HCPro, Inc., is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. This educational activity for 2.5 nursing contact hours is provided by HCPro, Inc. Commission for Case Manager Certification (CCMC) This program is approved by the Commission for Case Manager Certification for 6 Continuing Education Units. Disclosure Statement HCPro, Inc., has confirmed that none of the faculty/presenters, planners, contributors, or their spouses/partners have any relevant finan cial relationships to disclose related to the content of this educational activity. Disclosure of Unlabeled Use This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. HCPro, Inc., does not recommend the use of any agent outside of the labeled indica tions. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of HCPro, Inc. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.