July, 2009

BROUGHT TO YOU BY PHOENIX: THE HOSPITAL CASE MANAGEMENT COMPANY

Post Acute Follow-up Calls
There were a few questions on one of the case management discussion groups about case managers making post-acute follow-up calls. Phoenix endorses the use of post-acute follow-up calls and recognizes that it is often a first step in developing a robust community case management program to supplement the inpatient program. However, we do not believe that a clinician must make the call. Nursing, pharmacy and social work services typically participate in post-cute follow-up call programs but resources are scarce and must be used appropriately. Consider however, that if the call content is scripted to avoid open-ended questions that require clinical expertise to answer, the program can be managed by support staff. One creative client tapped into their extensive volunteer group and found retired health care workers who jumped at the chance! Call requests were referred to the group and questions were asked on behalf of the patient's case manager. They began with chronic CHF patients and the script included simple questions that could be answered by 'yes' or 'no' such as: "Did you weigh yourself this morning?" "Do you remember when your follow-up appointment is scheduled for?" Followed up by quality-focused questions such as: "Do you have any questions about your home care instructions?" "Do you have any questions about your medications?" Affirmative answers to these questions are referred to the pharmacist, case manager or social worker for call-back. Post-acute calls are the right thing to do for families and patients and if patients understand their post-acute instructions, we might be able to prevent readmissions.

Services not Status

http://www.cms.hhs.gov/transmittals/downloads/R1760CP.pdf

Sometimes we wish that a Medicare regulator would spend a day with us in a hospital.. Especially those charged with writing the rules. If you read the latest CMS transmittal effective July 1, 2009, then you know that we're referring to the new rules related to observation..........In an effort to clarify historically confusing language and rules, Medicare has removed references to 'admission' and 'observation status.' (see page 9 in transmittal 1760 - link below).

In the Medicare Claims Processing Manual, Pub. 100-02, chapter 6, section 20.6 and Pub. 100-04, chapter 4, section 290, CMS has made editorial changes related to outpatient observation services. Because the term “admission” is typically used to denote an inpatient admission and inpatient hospital services, CMS states that there is no payment status called “observation,” and reaffirms that observation care is an outpatient service, ordered by a physician and reported with a HCPCS Level II code. The newly 'clarified' language also speaks to the use of the term "direct referral" for observation services rather than a direct admission to observation care.

As reported in an HCPro memo, "some of the changes seem to move the terminology of observation services farther away from the reality of how observation is provided in hospitals. In the section on calculating observation time, the phrase “placed in a bed” was removed, but this doesn’t change the fact that most hospitals place these patients in beds alongside inpatients to receive these observation services".

In a related item, Trailblazer, the Medicare Administrative Contractor (MAC) for jurisdiction four (J4), conducted a review of claims and confirms that hospitals and physicians remain confused about the difference between inpatient and 'hospitalized' outpatients. Trailblazer’s sample of 250 claims on Type of Bill (TOB) 11X with diagnosis-related group (DRG) 247 and service dates between January and September 2008 had a 98.8 percent error rate. Reviewers found hospitals typically claimed routine inpatient admission following a postoperative outpatient procedure without documentation to support clinical complications.

We're not sure if the editorial changes in the Manual will help hospitals clarify the terms “observation” and “admission” when it comes to submitting claims, but we are confident that it will not help the physicians understand the complexities and implications of the rules.

What a field day for the RACs.

And finally, the transmittal reaffirms that "CMS encourages and expects hospitals to employ case management staff to facilitate the application of hospital admission protocols and critieria" within the parameters of the CoP. It does not prohibit the use of the 'admit per CM protocol' but implies that any protocol must meet CoP standards.

Link

Back to the Future

It was around 1985 when we first began reading about the New England Medical Center's outcomes based nursing delivery system. It was an innovative strategy to link the primary clinical nurse with selected physicians to manage a patient population more effectively. Not only did an outcomes orientation create accountability parameters, it was also a successful strategy to manage the patient's care more effectively in the new era of prospective payment.

Hospital case management evolved from those nascent beginnings. The only thing is, it came at the time when hospital execs were struggling to survive the new DRG payment system and were looking for any strategies to dramatically reduce costs. The New England nursing care model prompted many copy-cat programs but instead of capitalizing on the nurse-physician partnership, the new programs sprang from existing departments historically viewed as providing the mandated services thought to be more effective at reducing LOS and costs.

It didn't exactly work out that way and hospital executives today have re-opened their search for opportunities to reduce LOS and costs. This time, they are looking to recreate the original physician partnerships using case managers who have knowledge of both the clinical and financial issues affecting progression-of-care. Hospital case management is returning to its roots as outcome models take center stage. Today, outcomes based case management programs incorporate several features:

1. Clearly defined, measurable outcomes that reflect the influence of the case manager within a defined population.

2. Resources, objective information and tools to target opportunities to improve bottom line outcomes.

3. A case management team that pro-actively advocates for patients to protect them against the iatrogenic risk of unnecessary hospitalization and medical interventions.

4. The adoption of a process improvement perspective to facilitate safe navigation through the acute episode of care and often, beyond.

In July

Those of us who have spent their entire careers in the hospital industry know that July is not the best time for an elective admission in a teaching hospital for that's when the new class of interns arrive and are busy trying to figure out where the coffee lounge is located! But we like to think of this month as an opportunity as well. With their medical education focused on patient care, freshly minted interns/residents have little training in, or understanding of, the documentation process. What better time to begin a point-of-service documentation improvement program!

If your organization is lucky enough to have dedicated clinical documentation specialists (CDS), the rounding process in teaching hospitals is a perfect time to heighten everyone's awareness of the impact of proper documentation. Outfitted with wireless laptops and access to coding software, the CDSs can establish baseline DRGs during rounds and interact with the rounding team to identify potential MCCs and CCs. Because the CDSs are more visible during rounds, clinicians are bound to be more receptive to their queries.

If you don't have dedicated CDSs, the documentation improvement process must include a methodology for HIM to identify and share documentation improvement opportunities with the case managers who have the ear of the medical team during rounds.

In either case, this is the time to begin the intern's orientation to hospital life. Your organization might even want to consider the development of service line/diagnosis-specific discharge summary templates to make it easier for all physicians to include appropriate CCs. Using the rounding process (however its done at your facility), is a favorite starting point.

What's Your Brand?

Any hospital case management program that undergoes transformation from a functional to an outcomes model wants to be viewed differently today than they were last year. Every case mangement program intentionally or unintentionally creates a brand. While it may not be the desired brand, you most certainly have one. So, what's your brand? It's easy to find out.

Just ask five of your constituents "when you consider the case management program of yesterday and compare it to the one today, what do you think of?" If they give you that deer-in-the-headlights look, then you have a problem. On the other hand, they might say, "When it comes to you and your team, I think of a group of people working with the physicians and the rest of the clinicians to look after our patients' best interest." With that kind of reaction, you have developed an unassailable brand that makes you team stand out.

So how does this unassailable brand get built? Think of three concepts - all beginning with the letter V.

Vision:--A clear vision of how you will practice case management to support the medical staff and clinical team is essential. A vision is a compelling picture of your perfect practice and goals. You can't build a strong brandf if you and your teammates are unclear about where you are trying to go.

Values:--What is really central to your program's existance? What have you done so well that it has inspired nursing and medical staff engagement? You should come up with a list of values that sets you apart from other hospital programs.

Value:-- Great brands deliver value. Think of the Mr. Coffee coffee-maker - reasonable price and consistently good cup of coffee. That's value. What value do you bring to constituents that they can't obtain somewhere else? Here's a clue: It is not the services you provide. It's simply you and everything you stand for and deliver.

Ultimately, constituents look you in the eye and say to themselves, "Do I trust that this person will be a good steward of our resources while proactively advocating to ensure that the patient receives high quality care? A valued partner in my quest to provide quality care and value to the organization?"

Take some time to reflect how much real, sustainable value you provide to your constituents. Give some thought to this idea and the answer can be a resounding "Yes."