Case Management Monthly

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1 Best practices and practical solutions Case Management Monthly P3 P5 Reduce homeless patient readmissions With the right support and planning, case managers can help homeless patients maintain health and avoid additional admissions. Prevent ED discharge failures An AHRQ study examines common reasons why ED discharges fail and identifies potential solutions to prevent them. From the Director s Desk When case managers and physicians collaborate, patients experience safe transitions and increased satisfaction will be shared by all. Volume 12 Issue No. 2 FEBRUARY 2015 Complex Case One case manager takes on a search for a new patient s family. OIG Work Plan sets out tasks for case managers Learning objectives At the completion of this educational activity, the learner will be able to: Describe the OIG enforcement priorities related to case management duties Relate strategies to ensure compliance and avoid penalties Each year the Office of Inspector General (OIG) outlines its enforcement priorities. Its 2015 Work Plan includes items case managers should have on their radar. 2-midnight rule It s probably no surprise that 2-midnight rule enforcement is coming under the microscope. The OIG is going to be zeroing in on whether short hospital stays meet inpatient criteria according to the 2-midnight rule standard. The 2015 OIG Work Plan confirms its continuing focus on the application of admission criteria, says Stefani Daniels, RN, MSNA, CMAC, ACM, president and managing partner of Phoenix Medical Management, Inc., in Pompano Beach, Florida. They are going to continue to audit claims data and see if they can find patterns of short stays being billed as inpatients. The OIG will continue to enforce the False Claims Act by using claims data to scrutinize patterns and trends, looking for cases in which patients are admitted as inpatients when they should have been treated on an outpatient basis. If patterns are identified, they will request records and see if documentation supports expectation of a 2-midnight stay and the need for inpatient admission, says Daniels. Many organizations don t feel comfortable when it comes to compliance in this area. I am a bit nervous about what will happen when the audit contractors are released in 2015 to audit 2-midnight records, says Beverly Cunningham, MS, RN, vice president of resource management for Medical City Dallas Hospital. Tip: To help ensure compliance, make sure that the emergency department s utilization review specialist partners with the clinical documentation improvement coordinator to verify all documentation is complete and accurate at the time of admission, says Daniels.

2 Case Management Monthly February 2015 Coding clarity The OIG also wants to ensure that physicians are coding properly for treatment in different settings. The three-year guide is confusing because most physicians just aren t aware if a patient was seen in the hospital, in the ED, in his office by another associate, or by an ambulatory service area, says Daniels. But it might be a piece of information that case managers can share with their physician partners. Medicare rules stipulate that if a physician has treated a patient as an inpatient or outpatient in the past three years, the physician must characterize the patient as established, says Daniels. The OIG has determined that hospitals are submitting Part B claims using evaluation and management codes for new patients, which are paid at a higher rate, rather than the codes for an established patient, she notes. Tip: Case managers should remind their physician partners of this rule to avoid OIG scrutiny, says Daniels. Mechanical ventilation In the past, the OIG examined billing for DRGs related to mechanical ventilation to ensure patients assigned to ventilation received 96 hours or more. This topic is again climbing the audit priority list, says Cunningham. Tip: Review cases to ensure all patients on mechanical ventilation meet the standard. Postacute care equipment The OIG will also focus on proper use of supplies and equipment, including items such as power mobility devices, diabetes testing supplies, prosthetics, and nebulizers, says Cunningham. We have to be very diligent and not let these things slow down patient flow. They also could potentially increase readmissions, she says. Tip: Flag cases involving supplies and equipment early in the hospital stay to ensure that protocols are followed and that patients get timely access to supplies. Look back as well as forward Ultimately, while the OIG Work Plan gives providers a starting point to ensure compliance, recognize that anything an organization was penalized for in the past can always resurface, says Cunningham. Tip: Look back on past mistakes to make sure you re not repeating them in the present. H This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. EDITORIAL ADVISORY BOARD Product Specialist Andrea Kraynak akraynak@hcpro.com Follow Us Follow and chat with us about all things healthcare compliance, management, and Contributing Editor Kelly Bilodeau Jackie Birmingham, RN, BSN, MS, CMAC Vice President Emeritus, Clinical Leadership Curaspan Health Group, Inc. Newton, Massachusetts Stefani Daniels, RN, MSNA, CMAC, ACM President and Managing Partner Phoenix Medical Management, Inc. Pompano Beach, Florida Wendy DeVreugd, RN, BSN, PHN, FNP, CCDS, MBA Regional Senior Director of Case Management Kindred Healthcare, Hospital Division, West Region Westminister, California Deborah K. Hale, CCS, CCDS President Administrative Consultant Service, LLC Shawnee, Oklahoma Robert Marder, MD Practice Director of Quality and Patient Safety The Greeley Company Danvers, Massachusetts Peter C. Moran, RN, C, BSN, MS, CCM Nurse Case Manager Massachusetts General Hospital Boston, Massachusetts Loretta Olsen, MSN, RN, ACM Director of Case Management Mercy Medical Center North Iowa Mason City, Iowa June Stark, RN, BSN, MEd Director of Care Coordination St. Elizabeth s Medical Center Boston, Massachusetts Karen Zander, RN, MS, CMAC, FAAN President and CEO The Center for Case Management, Inc. Wellesley, Massachusetts Case Management Monthly (ISSN: [print]; [online]) is published monthly by HCPro, 75 Sylvan St., Suite A-101, Danvers, MA Subscription rate: $379/year. Case Management Monthly, 100 Winners Circle, Suite 300, Brentwood, TN Copyright 2015 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be repro-duced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial com-ments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro.com. Visit our website 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. 2 HCPRO.COM 2015 HCPro, a division of BLR. 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 February 2015 Case Management Monthly Reducing readmissions among homeless patients Learning objectives At the completion of this educational activity, the learner will be able to: Describe the role homelessness plays in readmission risk Describe strategies that can help reduce readmission risk amongst the homeless population Develop strategies that case managers can use to help reduce readmissions among this population Considering the daily challenges homeless individuals face, their high readmission rate should be unsurprising. Properly managing one s health is difficult for those worried about where they will sleep or find their next meal. One study published in the September 2013 issue of Medical Care, The Revolving Hospital Door: Hospital Readmissions Among Patients Who Are Homeless, shows that homeless patients very often wind up back in the hospital within 30 days of discharge. Study authors found that 113 homeless individuals made 266 trips to the hospital during the study period. Half (50.8%) of all hospitalizations resulted in a 30-day hospital inpatient readmission, and 70.3% resulted in either an inpatient readmission, observation status stay, or emergency department (ED) visit within 30 days of hospital discharge, according to the study. Most readmissions occurred early after hospital discharge (53.9% within one week, 74.8% within two weeks). Because the risks of readmission are so high for this population, experts say hospitals should put strategies in place to reduce them. Below are some ideas for helping prevent readmissions among homeless patients as well as improve their quality of life and health. Help them forge ties To help protect the health of homeless patients, give them a lifeline to community resources. Start the process by matching them with a shelter or homeless housing, says June Stark, RN, BSN, MEd, director of care coordination at St. Elizabeth s Medical Center- Steward Healthcare in Boston. The next resource to look for is a local clinic that provides free services. Also try to identify a regular physician whom the patient can see consistently for care, says Stark. Ideally, the nurse case manager should try to meet the patient at his or her first free clinic visit (or all of the visits, if possible) to help guide care and ensure the patient s needs are met. Look for forgotten benefits Many times homeless individuals might be entitled to benefits they ve forgotten about. Case managers assessing resources for patients who are homeless need to ask the patients about his or her military status, says Jackie Birmingham, RN, MS, vice president emerita, clinical leadership for Curaspan in Newton, Massachusetts. Even the patient who is a veteran might not know about this critical resource. Asking this question at the time of admission can help reduce homelessness among veterans. We owe it to them to get them connected, says Birmingham. Taking this step may prevent readmissions and improve the quality of life for veterans. One resource to check for those with veteran status is homeless. Plan for medication issues Case managers need to identify a way for homeless patients to get all of their prescription medications. Just giving the patient a list of items is insufficient; make sure they have access to them, says Stark. Teaching the patient how to take medications properly is also critical. Medication errors are a major source of readmissions, so ensuring proper education is not something that case managers should skip, she says. Monitor care Matching a patient with services is just the beginning, says Stark. Case management should also ensure that the homeless individual s care is continually monitored. A designated case manager should visit the shelter on a weekly or even more frequent basis to monitor the patient s vital signs and verify treatment 2015 HCPro, a division of BLR. 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 February 2015 compliance, she says. Doing so can help identify problems early before they necessitate a costly readmission. Observe nutritional status Medication and medical treatments help keep people healthy and out of the hospital, but food is a critical component as well. If a patient doesn t have adequate nutrition, chronic conditions such as diabetes may be exacerbated. Before the patient leaves the hospital, case management should develop a nutritional plan and find local resources to help meet the patient s needs. Find social support and family Often patients have family members with whom they ve lost touch but who may be able to help them out. Putting them back in touch with those individuals can sometimes help. In the absence of family or friends, linking the patient to social supports can also help ensure program success. Doing so contributes to building patients self-worth and life purpose, says Stark. Consider medical respite care In some cases, a homeless patient who is not sick enough to stay in the hospital but is too sick to leave may qualify for another option medical respite care. This is a short-term residential placement in a shelter, transitional housing, nursing home, or freestanding facility where the patient can recover, according to the National Healthcare for the Homeless Council. Learn more at medical-respite. Plan ahead In addition to linking patients to community resources, develop a plan for those patients who excessively use the ED. The community case manager should collaborate with the ED case manager to develop a plan to eliminate or minimize ED usage, says Stark. The ultimate goal is to shift care for nonurgent issues to the community case manager and free care clinic. Inform yourself To best help your homeless patients, understand their rights and the resources available to them, notes Peg Rossi in the HCPro book The Hospital Case Management Orientation Manual. She suggests getting familiar with shelter schedules and finding safe transportation to help patients get there. Also be sure to find out ahead of time whether the shelter allows home health referrals for patients. Some don t, which could mean they can t get health support in that setting. Rossi also suggests ensuring that each homeless patient has at least a three-day supply of needed medication and supplies before they leave the facility. With the right amount of support and planning, case managers can help homeless patients maintain their health and avoid the need for additional hospital admissions. H Continuing education information Nursing Contact Hours (ANCC) HCPro is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. 2.5 Contact Hours for nurses are available each quarter (March, June, September, December). Commission for Case Manager Certification (CCMC) This program is approved by the Commission for Case Manager Certification for 6 Continuing Education Units per quarter. To obtain your contact hours you must: Read each issue of Case Management Monthly within the quarter 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 continuing education hours expire after one year. Disclosure statement: The planners, authors, and contributors for this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. 4 HCPRO.COM 2015 HCPro, a division of BLR. 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 February 2015 Case Management Monthly Prevent ED discharge failures Learning objectives: At the completion of this educational activity, the learner will be able to do the following: Describe the risk factors for ED discharge failures Relate three components of a succesful ED discharge Describe some screening tools used to assess dischargefailure risk After physicians treat them in the emergency department (ED), millions of patients each year head home to recover, but not all of them do so successfully. Many wind up needing to head right back to the hospital because something goes wrong and the discharge fails. These discharge failures are often caused by a few recurring factors, such as patients not understanding how to take their medication or not following their physician s treatment advice. The Agency for Healthcare Research and Quality (AHRQ) recently partnered with the Johns Hopkins University Armstrong Institute for Patient Safety and Quality to study this issue. Researchers examined stacks of literature to find the most common reasons why discharges fail and to come up with some potential solutions to prevent these issues. Their goal was to answer three questions: 1. What are the risk factors for patients at high risk for discharge failure? 2. What are the identified, demonstrated, or proposed interventions to improve the ED discharge process? 3. What are the metrics to measure the effectiveness of the ED discharge process? The researchers found that a successful discharge has three components: 1. Staff members successfully educate the patient about his or her illness and treatment plan 2. The organization provides support to the patient after discharge 3. Staff members help the patient coordinate care with other healthcare providers and community organizations Case managers play an important role in the coordination of care. While case managers have many responsibilities, their most important role in improving discharges from the emergency department is guaranteeing care coordination based in the emergency department, says Barbara Bartman, MD, a senior medical officer with AHRQ s Center for Quality Improvement and Patient Safety. This requires the provision of assistance with follow-up outpatient appointments, medical insurance, prescriptions, transportation, and housing. A single intervention may suffice, or a patient may benefit from receiving several interventions and strategies at once, frequently referred to as a bundle. Today s healthcare environment is making care coordination and collaboration critical. New market forces driving increased emphasis on patient choice related to quality reporting and the need for reductions in the total cost of care make the need for coordinating care across formerly independent (and often siloed) entities a question of when, no longer if, says Becca LaFond, MBA, MHA, managing director of Huron Healthcare in Chicago. As the authors point out, an effective ED discharge is no longer simply the end to an episode of care at one location, but needs to be the coordination of that episode of care within the context of the broader healthcare system. ED (and other) case managers are uniquely positioned and trained to drive this change. Today the industry is moving from a fee-for-servicebased model to population health management. This means that there are now financial incentives to ensure patients discharging from the ED leave with the appropriate plan of care, understanding of their condition, next steps, and knowledge of where to seek care in the future, says LaFond. The ED discharge process is crucial for ensuring high patient and care team satisfaction, reducing preventable readmissions to the hospital, and improving quality of care, she says. Screening for risk factors One of the first steps any hospital should take is to identify patients who might be at high risk for discharge failure at the time of admission HCPro, a division of BLR. 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 February 2015 The AHRQ report says that these patients tend to have common risk factors, which include the following: Lack of insurance or inadequate insurance Homelessness Low income Lack of a primary care provider (PCP) Poor comprehension or health literacy Alcohol dependence Drug use Psychiatric illness Physical or cognitive impairment Various medical conditions and chief complaints Advanced or young age Being male Prior frequent ED visits A number of screening tools can help organizations screen for these risk factors. The tools researchers looked at include: Rowland Questionnaire Triage Risk Stratification Tool Identification of Seniors at Risk Runciman Questionnaire Hegney Tool Complex Model The most accurate tool was the one used to gauge the risk of discharge failure among older individuals. The Rowland questionnaire had 88% sensitivity, 72% specificity, and 98% negative predictive value of ED revisit at 14 days, according to the study. The screening tools mentioned are all helpful in predicting and identifying patients at high risk of readmission or ED revisit, says LaFond. Using these tools to utilize scarce care coordination resources targeted at high-risk populations (rather than all patients, if resources are constrained) makes sense. Some case managers might not focus on highrisk populations for a number of different reasons, but if they don t, they should consider doing so. Intervention programs often target all patients or patients selected at random (to receive follow-up calls, as an example), says LaFond. While these solutions certainly benefit the patients who receive them, they may not be targeting the patients in the community who would benefit most from these types of interventions or who are at highest risk for discharge failure. Making discharges stick After identifying those at highest risk for discharge failure, the AHRQ also identified a number of practices that hospitals can adopt to improve the discharge process. Some of those interventions include: Discharge instructions and education. This doesn t just mean handing patients a piece of paper with written instructions and sending them out the door; staff members should teach patients and verify their understanding before the patient leaves. Telephone follow-up. Calling patients after discharge can help identify potential problems before they become serious enough for a return visit to the hospital. ED-made appointments. Make the followup appointment with a primary care physician or specialist while the patient is in the emergency department if possible, says Bartman. Some studies have shown that patients are more likely to get follow-up care if hospital staff members make the appointment before discharge. Check for insurance coverage. Determine if the patient has medical insurance coverage that will cover the follow-up visit, says Bartman. If the patient does not have medical insurance coverage, notify the emergency department physician and suggest a referral to a practitioner or local clinics that will provide care regardless of insurance status. Then provide resources to the patient so that he or she can explore insurance options. Prescription assistance. Patients who can t afford prescriptions ultimately won t take them. Helping them get the medicine they need can improve those odds of a successful discharge. Advocate for dispensing emergency department discharge priority medications from the emergency department s in-house outpatient pharmacy, says Bartman. One example is prednisone for asthma patients. Transportation assistance. Helping patients get to primary care appointments and the pharmacy may make it more likely that they will follow recommended care guidelines. Maintain and grow a network of providers, individuals, and organizations in the community who have programs available to 6 HCPRO.COM 2015 HCPro, a division of BLR. 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 February 2015 Case Management Monthly assist patients with transportation and housing, says Bartman. Establish a multidisciplinary team. Case managers from varying disciplines who work together to provide care coordination can be complementary for example, having both a nurse and a social worker, says Bartman. Use screening protocols. Implement the use of screening tools to predict emergency department revisits and establish outcome metrics, process metrics, and financial metrics to continually assess progress, says Bartman. Care coordination coupled with a risk screening process achieved greater success than efforts aimed at a more general population. Work together. Use multidisciplinary group meetings that include patients to improve post emergency department care for those individuals who are frequent emergency department users, says Bartman. Barriers to discharge The figure below shows the barriers that may lead to an emergency department discharge failure. ED failure to reconcile medications ED failure to coordinate postdischarge care Suboptimal patient education at discharge Noisy, chaotic work setting Inadequate information (e.g., about PCP, meds) Educate/ communicate with patients Overcrowded work setting Support post- ED discharge care Short encounter timeframe ED failure to communicate with primary care provider Patient failure to follow treatment plan Inadequate community support services (e.g., transportation) Patient risk factors (e.g., limited selfcare capacity) Coordinate care with other providers and services Patients lack primary care provider Patients lack insurance Patient failure to follow up with specialist Patient failure to access postdischarge/ community services Patient failure to follow up with primary care provider Source: Johns Hopkins University, Armstrong Institute for Patient Safety and Quality. Improving the Emergency Department Discharge Process: Environmental Scan Report. (Prepared by Johns Hopkins University, Baltimore, MD, under Contract No. HHSA ) Rockville, MD: Agency for Healthcare Research and Quality; December AHRQ Publication No. 14(15)-0067-EF HCPro, a division of BLR. 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 February 2015 Another factor that can contribute to discharge success is good communication and collaboration, according to LaFond. Although ED case managers are in the right position to help coordinate the discharge process and the interventions cited in this report, it takes the entire care team to truly impact the quality, patient satisfaction, and financial outcomes, says LaFond. ED case managers need to collaborate with the ED nurses, the ED medical staff, social work, and other care team members to accomplish the many goals cited in the report in what is a very short window of intervention opportunity (the ED visit and the few days following). The report shows that one hospital or department can t coordinate care by itself. While new payment models are forcing hospitals and health systems to address this, the industry is a long way from achieving true care coordination, says LaFond. Proactive and appropriately resourced ED case management, however, is a good start on a long journey! Whatever changes a hospital makes make to improve ED discharge success, it must regularly monitor results. There are a number of different measures to look at, from return visits to the ED within 72 hours to tracking post-discharge phone calls. Ultimately, though, your patient s health result will let you know the program is working. The true measure of success, says LaFond, is better health outcomes for your patients who are at higher risk for an ED discharge failure. H Outlining discharge goals To be successful, an emergency department discharge should ideally include a number of different functions. Below is a chart from the Agency for Healthcare Research and Quality (AHRQ) report, Improving the Emergency Department Discharge Process: Environmental Scan Report, which shows what a discharge should achieve. Broad functions of ED discharge process Communicate With/Educate Patients Communicate with patients what occurred during the ED visit (treatments, tests, procedures) Educate patient on diagnosis Educate patient on treatment plan Communicate with patients about reconciled medication list Educate patient on expected course of illness Educate patient on signs and symptoms to watch for Support Post-ED Discharge Care Ensure patients appropriately take new medications Ensure patients stop or avoid taking certain medications (depending on condition) Ensure patients are capable and able to care for wounds Ensure patients understand and comply with dietary restrictions Ensure patients can receive the appropriate physical therapy (depending on condition) Discuss use of medical devices (crutches, walker, neck brace, inhalers, glucometers, etc.) Discuss activity restrictions Facilitate further diagnostic testing Facilitate further health care provider evaluation and treatment Coordinate Care With Other Providers and Services Share records with primary care physician (PCP) and specialists Communicate further plans with PCP and specialists Make appointment with PCP and specialists Facilitate admission to substance abuse recovery facilities Facilitate public housing services Source: Johns Hopkins University, Armstrong Institute for Patient Safety and Quality. Improving the Emergency Department Discharge Process: Environmental Scan Report. (Prepared by Johns Hopkins University, Baltimore, MD, under Contract No. HHSA ) Rockville, MD: Agency for Healthcare Research and Quality; December AHRQ Publication No. 14(15)-0067-EF. 8 HCPRO.COM 2015 HCPro, a division of BLR. 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 Collaboration between physicians and case managers is crucial by Peggy Rossi, BSN, MPA, CCM Regardless of the setting, collaboration in healthcare is one mechanism to help produce positive outcomes and satisfaction. While it is important for every area, collaboration between the case management staff and physicians is particularly vital. Working together, the physician and case management staff members need to accomplish the following: Outline the discharge or transition plan, clearly communicate it to the patient and providers, and make sure the plan is safe and ready for implementation when the patient is deemed medically stable for discharge. Clearly demonstrate medical necessity. This will help to ensure accuracy of utilization reviews and, in turn, accuracy of payments for services rendered. Consistently communicate the same message not only amongst the various team members, but also to the patient and family. Unfortunately, effective collaboration between nurses and physicians can be a challenge. Why? In most cases, traditional barriers exist, such as gender, race, language, and class differences, but the organization s hierarchical structures and the processes that employees must follow also present obstacles. Possibly the greatest challenge is that many physicians believe they are the final step in the clinical decision-making process. As long as the patient is progressing as expected, collaboration usually proceeds fluidly. Stressors enter the picture and conflicts arise more often when matters aren t going well. Collaboration may fall by the wayside, often owing to the different education, political agendas, and objectives of medicine versus those of nursing the same tenets that help form an individual caregiver s professional identity, values, and skills. Under difficult circumstances, staff tends to draw boundaries regarding who owns what or who will be responsible for specifics aspects of the work required. Collaboration is then put to the test. A sicker population is now accessing healthcare than once did. Shorter inpatient stays and reduced numbers of safety net providers in the postacute arena are becoming the norm, and without effective, ongoing communication and collaboration amongst the healthcare team, especially between the attending physician(s) and case manager, successful patient outcomes are placed in jeopardy. Collaboration entails: Direct and open communication Mutual respect for different points of view Shared responsibility for problem-solving Trust So, what do case managers need to do? At a minimum, they must understand: The patient(s) in their caseload (i.e., basics of their diseases and what might be called for at discharge or transition, what is needed to prove medical necessity when a utilization management review is required, etc.) The various levels of postacute care services, what each level means, and what each level can and cannot provide The basic elements of healthcare benefits, including the most common reasons a service could be denied or not considered a benefit at all The alternate funding programs for which a patient might be eligible The community resources available to augment care if benefits are limited or excluded When all the members of the healthcare team collaborate, including the physicians, a win-win situation occurs. The patient will experience a safe transition, and increased satisfaction will be shared by all. H EDITOR S NOTE Rossi is senior trainer and auditor for CA Health and Wellness and a consulting associate for the Center for Case Management in Wellesley, Massachusetts. A supplement to Case Management Monthly February 2015

10 Complex Case Case manager takes on a search for family One November afternoon, Tammy, the medical case manager at a community hospital, admits Bob, an 88-year-old patient with myocarditis who is experiencing confusion for the first time. Bob is unknown to Tammy, as he lives in a neighboring town and formerly used the hospital closer to his home. Staff members administer a mental status examination, and Bob only knows his name, address, and the current date. Tammy initially worries that she won t be able to gather the critical admission information about Bob to properly care for him, but soon several neighbors begin to visit. These neighbors have known Bob for years they have all lived in the same apartment building for nearly three decades. Because they know Bob well, the neighbors prove to be a vital source of information and support. But Tammy is still looking to identify next of kin to become the patient s healthcare proxy and to provide approval for treatments and rehab placement. The neighbors are able to tell Tammy much of what she needs, except for information about a living relative. Bob is always friendly, they say, but he never speaks of having any family at all. The neighbors tell Tammy that Bob has been an administrative assistant to a prominent state senator for the same length of time that he has lived in their apartment building. They also tell Tammy that Bob has several cats who are cared for by Nancy, a trusted, paid pet care provider. Later in the stay, when Bob s mentation starts to clear, he is able to identify Nancy by name and relay information about her. It is clear to all that Nancy is a close friend, more than just an assistant. With all this information, Tammy begins her detective work to track down a family member and determine whether he or she is available and willing to be a decision-maker for Bob s care. Tammy starts by gathering knowledge from the usual sources, searching by Social Security and insurance coverage. She learns that Bob, being a state employee, is covered by a government insurance plan in addition to Medicare Part A; he also has a pension. The next step she takes is to call the senator s office, where she finds that the present administrative assistant knows Bob well and is able to confirm the information provided by the neighbors. Bob is a well-respected employee whom the senator speaks about frequently and still keeps in touch with. But despite their continued relationship, Bob has always kept to himself, and in all the years of working at the same job, he has never spoken of any family. Tammy feels like she has hit a dead end in her search, but then remembers that Bob has previously been a patient at his hometown s hospital. Tammy knows that hospital s manager of case management very well and decides to call her. The manager is glad to hear from her colleague and shares a piece of vital information: Bob has a cousin in a nearby state. The manager shares the cousin s address and phone number along with the elements of the previous discharge plans, including all the home care and elder services that were provided. Tammy s plan is to contact Bob s cousin, but the phone number she has is not working. Tammy calls the local town hall and has to speak to three different departments. At the end of her search, which takes days, Tammy learns that both Bob s cousin and his cousin s wife have died. The cousin s daughter is still living, but Tammy cannot not reach her after numerous attempts. The hospital lawyer is consulted, and a psychiatric consult is completed. The hospital lawyer feels comfortable with the results of the psychiatric consult, which indicates that the patient s confusion is temporary and expected to clear over the next weeks after the patient completes his course of antibiotics. In fact, Tammy and some of the medical healthcare team are already beginning to see obvious signs of clearing. Tammy, with guidance from the risk manager, begins the screening process for Bob to transition to a rehab facility. She does this to be proactive as she waits for Bob s mental status to improve to the point that he can make this decision himself. Also, because Tammy could reach no living relatives that knew Bob, she plans to discuss the possibility of making Nancy his healthcare proxy. Bob improves over the next week and eventually transfers to a rehab of his choice. H CMM, 100 Winners Circle, Suite 300, Brentwood, TN Telephone Fax