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| Grant Funds | |||
 On April 15, $50 million in grants was awarded through a competitive process to twenty state Medicaid agencies for a 2 - year period to establish alternate non-emergency service providers or networks of such providers. The grants will allow States to establish outpatient programs so that treatment can be received in an alternate settings for the same conditions and with potential lower cost obligations for beneficiaries. For a list of the grant projects, click on the link below. The alternate programs include primary care clinics, outreach case managers as an extension of hospital EDCM programs, medical homes, targeted outreach using redirection management, and referral coordinators loated in hospital emergency departments. If you work at one of the hospitals who received the grant, congratulations and let us know your experience. » click here |
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| The Benefit of a CM-ANP | |||
 The case management program in an Oregon hospital has two advanced nurse practitioners (ANPs) on their team working with specially targeted physicians. When the EDCM program at this client hospital identified a large population of unassigned patients, the hospital dangled a carrot in front of one of the new commuity physicians. "Provide medical management to this needy population," the physicians were told "and we'll give you a dedicated case manager to help manage the inpatients during your absence from the hospital."The physicians agreed and the program director jumped at the chance to integrate these highly proficient clinical experts into the case management team. As the newest team members, the ANPs recognized their limited knowledge about the business of healthcare, and the seasoned case managers recognized that they could use some clinical coaching. According to the Director, it was a win-win-win-win-win situation: The physicians, the case managers, the ANPs, the hospital and the patients all benefitted. And because ANPs are able to practice independently in Oregon, the hospital was able to bill for their services under Part B using the ANPs' provider numbers. |
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Clinical Documentation
We've written alot about clinical documentation improvement programs (CDI) and are convinced, now more than ever, that if a hospital is going to get full and complete reimbursement for the care they are providing to a growing population of severely ill patients, it must address the CDI issue quickly. During the last three months of hospital visits, we've met with many HIM Directors, and they all cast the same warning - the new MS-DRG system will create significant reimbursement shortfalls unless the physicians learn a new way of documenting illnesses.Many hospitals introduced CDI through its case management program. The thinking was that since many case management activities were chart-based, the case managers could just as easily review medical documentation for improvement opportunities. Case managers spent weeks in the classrooms preparing for their new role as pseudo-coders. However, once back on the units, they found that much of their time was spent reviewing medical documentation with little time left for anything else.
Executives eventually acknowledged that adding this new burden to the CMs' list of tasks resulted in diminished attention to case management activities. This approach disappeared almost as quickly as it was introduced and CDI was carved out as a separate function and dedicated CDI specialists were hired. The specialists were typically nurses and they typically remained under the case management umbrella. In this way, it was envisioned, while the case manager and the physician were conferring about the care plan, they could also discuss documentation opportunities.
Lately however, we notice a shift. CDI programs are moving to Health Information Management (HIM) departments where they have access to the latest Coding Clinic guidelines and other regulatory information, and the individuals being recruited as CDI specialists are coming from HIM specialties. From professional level RHITs to certified coding specialists, these positions are now in high demand. The connection between the case managers and the CDI specialists, however, is still crucial. .
If you are in one of the hospitals where the above scenario is being played, we urge you to establish a routine process of sharing documentation improvement information between CM and HIM so that one team can help the other achieve the outcomes each desires.
print this articleADT Magic
There are three reasons why a patient's admitting diagnosis should be known at the time of registration. First, there is the issue of quality. If the case manager or quality specialist knows from the outset that a patient may be part of a cohort of patients who are eligible for evidence based protocols and order sets or will be monitored for quality measures, it will trigger immediate action.
Secondly, knowing the tentative admitting diagnosis can generate a working DRG which in turn can provide the expected LOS and reimbursement. Each piece of information will be be valuable in working with the physician to advance the treatment plan and monitor resource utilization.
And thirdly, with the MS-DRG system, medical documentation will be key to fiancial solvency. Advising physicians on possible MCCs or CCs related to a diagnosis will be a whole lot easier if the working DRG or tentative principle diagosis is known from the onset.
Right now the system of assigning principle diagnoses or DRGs is a retrospective process. Hospitals are using CDI specialists or they are hiring concurrent coders to produce the working DRG so that the quality people have the information they need to monitor compliance.
The new information systems give the organization an option to get this information prospectively and concurrently. Right now, in the vast majority of hospital registration offices, there is a free-text field in which the clerk has to enter an admitting diagnosis. Forgive us if we chuckle around this time, because like you, we have seen some very creative admitting diagnoses typed in this field. Consider however, that many of the newer, Windows-based ADT systems have drop-down tables that contain key ICD languarge diagnoses. Instead of typing, the clerk must ask the physician or nurse the probable diagnosis and choose it from among those listed on the table. With a formal ICD diagnosis now in the system, electronic wizardry can then generate a working DRG, the GMLOS and anticipated reimbursement - all right on the face sheet!
Think of the jump start case managers, quality, performance improvement, and documentation improvement specialists will have with quick access to this information. Speak to your CFO or CIO today and have them call your vendor to find out if your system has this technical capability. You'll be glad you did.
print this articleGain-sharing back in the News
As many of you know, federal anti-kickback statutes, the Stark law preventing physician self-referrals and Social Security Act provisions have kept gain-sharing initiatives modest. But in 2005, the OIG began improving a series of narrow gain-sharing efforts. This year, CMS will sponsor two demonstration projects over a three year period to test whether financial incentives made by hospitals to physicians will improve quality while reducing costs. Up to 72 hospitals are being selected for the larger program and 6 hospitals, of which two are rural, will look at short term effects of gain-sharing.source: Modern Healthcare, 12/07
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