Access Point Case Managers: The Lynchpin for Hospital Admissions Toni G. Cesta, Ph.D., RN, FAAN Partner and Consultant Case Management Concepts, LLC East Coast Office North Bellmore, New York Bev Cunningham, MS, RN Vice President Clinical Performance Improvement Medical City Dallas Hospital And Partner and Consultant Case Management Concepts, LLC Southern Office Dallas, Texas Tuesday, April 29th, 2014 The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. Opinions, references and links provided by our speakers are provided for your convenience and do not represent our endorsement of such opinions, products or services.
Transcript
Access Point Case Managers: The Lynchpin for Hospital Admissions
Toni G. Cesta, Ph.D., RN, FAANPartner and Consultant
Case Management Concepts, LLCEast Coast Office
North Bellmore, New York
Bev Cunningham, MS, RNVice President ClinicalPerformance Improvement
Medical City Dallas HospitalAndPartner and ConsultantCase Management Concepts, LLCSouthern OfficeDallas, Texas
Tuesday, April 29th, 2014
The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. Opinions, references and links provided by our speakers are provided for your convenience and do not represent our
endorsement of such opinions, products or services.
FACULTYToni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and
evaluating acute care and community case management models, new documentation systems, and other strategies for improving care and reducing cost. The author of eight books, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management. Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management. Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York.
Bev Cunningham, RN, MS is Vice President, Resource Management at Medical City Dallas Hospital. Her areas of responsibility include Case Management, Health Information Management, Clinical Documentation Integrity, Patient Access and Transplant Financial Services. Bev is a well‐known speaker in the Case Management field. Involved in the development of case management for over twenty five years, her areas of expertise include denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process. She has served as a Commissioner on the Commission for Case Management Certification. Bev is also a partner and consultant in Case Management Concepts, a company that provides support to hospitals regarding effective Case Management model development and evaluation. Bev's publications include a chapter in CMSA's Core Curriculum for Case Management Certification and most recently, co‐author of the book, Core Skills for Hospital Case Management. She is also on the advisory board for Hospital Case Management.
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1. Discuss the role of access point case manager.2. Review how the role of access point case
manager can be implemented when considering all patients admitted to the hospital.
3. Explain new and revised case management standards, regulations, and laws put forth by CMS, TJC and the federal government.
4. Evaluate case management protocols and penalties.
LEARNING OBJECTIVES
EARLY CASE MANAGEMENT MODELS
DID NOT GIVE GREAT ATTENTION TO THE TWO FUNDAMENTAL ROUTES OF ENTRY TO THE HOSPITAL
ACUTE CARE SETTINGS NOW RECOGNIZE THE IMPORTANCE OF GATEKEEPING ACCESS POINTS
BY THE NUMBERS
IN 2008, 124.9 MILLION PEOPLE VISITED EMERGENCY ROOMS. OF THESE 113.3 MILLION CAME FROM PRIVATE RESIDENCES AND 3.45 MILLION FROM NURSING HOMES OR OTHER RESIDENCES
MORE THAN 9 IN 10 ED VISITS IN 2008 WERE RELATED TO ACUTE CONDITIONS, AND HALF OF THESE ALSO INVOLVED CHRONIC CONDITIONS. INJURIES COMPRISED 1 IN 4 ED VISITS.Agency for Healthcare Research and Quality
MORE BY THE NUMBERS
ED VISITS FOR PEOPLE BETWEEN AGES 65 AND 74 HAVE INCREASED THE MOST OVER THE LAST DECADE AND ARE PROJECTED TO NEARLY DOUBLE FROM 6.4 MILLION IN 2005 TO 11.7 MILLION BY 2013
Centers for Disease Control and Prevention
EVEN MORE
IN 2007, ABOUT 10% OF THE POPULATION UNDER AGE 65 VISITED THE ED FOR REASONS THAT WERE CONSIDERED NON-URGENT, DEFINED AS THOSE FOR WHICH THE PATIENT SHOULD BE SEEN WITHIN 2 HOURS TO 24 HRS OF ARRIVAL
Annals of Internal Medicine, 9/11/07
TOP TEN REASONS WHY YOU MUST HAVE ED CASE
MANAGEMENT1. Assignment of appropriate level of care from
the point of entry2. Manage the 2-Midnight Rule3. Recovery Audit Contractors (RAC)4. Reduction in readmissions5. Improvement of in-patient through-put6. Reduce the need to use Condition Code 447. Assure compliance with medical necessity8. Reduce commercial admission denials9. Manage observation service10. Increase patient satisfaction in the ED
THE NON-EMERGENCY IN THE EMERGENCY ROOM
INCREASING ED VISITS SUBSTANTIATED OVER LAST DECADE
MUCH OF THE INCREASE IS ATTRIBUTED TO THE USE OF EDs FOR NON-URGENT COMPLAINTS
BIG PUSH TO KEEP PATIENTS OUT OF THE HOSPITAL
A PROBLEM OF CARE DELIVERY TO THE POOR
WHAT DOES THE NON-EMERGENT PATIENT LOOK LIKE–LACK OF PHYSICIAN ACCESS–LACK OF PERSONAL PHYSICIAN–MEDICAID AS PAYER
THE NEW ED
IT IS AN ACCESS POINT IT IS ALSO AN EXIT POINT IF IT ISN’T AN EXIT POINT, YOU
REALLY DO NEED ED CASE MANAGEMENT
GOALS OF ACCESS POINT CASE MANAGEMENT
MANAGE AND CONTROL THE TYPES OF PATIENTS APPROVED FOR ADMISSION
PROVIDE FOR ALTERNATIVE CARE WHEN NEEDED AND APPROPRIATE
ENSURE HOSPITAL REIMBURSEMENT
ADMITTING DEPARTMENT CASE MANAGEMENT
PROVIDES GATEKEEPING FUNCTION FOR:–PLANNED ADMISSIONS–URGENT ADMISSIONS–DIRECT ADMISSIONS–TRANSFERS
ROLES AND FUNCTIONS
SCREENING OF POTENTIAL ADMISSIONS/TRANSFERS–USE CLINICAL INDICATORS–COMPARE PT’S SEVERITY OF ILLNESS
AND INTENSITY OF SERVICEAGAINST ESTABLISHED CRITERIA
ROLES AND FUNCTIONS
WHEN THE PATIENT’S NEEDS DO NOT MEET ADMISSION CRITERIA, THE PHYSICIAN IS CONTACTED
CARE ALTERNATIVES ARE DISCUSSED
ALTERNATIVE LEVELS OF CARE/SETTINGS
AMBULATORY SURGERYOBSERVATIONHOME CARESUB-ACUTE
LINK PATIENT NEEDS TO APPROPRIATE SETTING
NEVER DENY AN ADMISSION WITHOUT PROVIDING THE PHYSICIAN WITH ALTERNATIVE SETTINGS ALONG THE CONTINUUM THAT WOULD MORE APPROPRIATELY MEET THE PATIENT’S CLINICAL NEEDS AND ENSURE REIMBURSEMENT
SCREENING TRANSFERS
ENSURE THAT THE TRANSFER IS APPROPRIATE AND MEETS ALL MEDICARE GUIDELINES
AFTER ADMISSION APPROVAL
CASE MANAGER COMMUNICATES TO THE ADMITTING OFFICE
IF HOSPITAL HAS BED TRACKERS, THEY MAY ALSO NEED TO BE NOTIFIED
CM OBTAINS PRE-AUTH OR APPROVAL FROM INSURANCE COMPANY
REQUESTS FOR CLINICAL INFORMATION
IF INSURANCE COMPANY (THIRD PARTY PAYER) REQUESTS ADDITIONAL CLINICAL INFORMATION, THE CASE MANAGER MAY BE THE APPROPRIATE PERSON TO PROVIDE THE LINK BETWEEN THE CLINICIANS, ADMITTING DEPARTMENT AND INSURANCE COMPANY
SAME-DAY ADMISSIONS
REVIEW PRIOR TO DAY OF SURGERY TO ENSURE THAT PRE-AUTH HAS BEEN OBTAINED
PRE-ADMISSION TESTING
MEET AND “INTAKE” SELECT PATIENT GROUPS DURING PRE-ADMISSION PROCESS
IDENTIFY ANY PRE-ADMISSION ISSUES THAT MIGHT AFFECT THE IN-HOSPITAL STAY AND/OR DISCHARGE PLAN
EXPLORE DISCHARGE PLANNING OPTIONS WITH PATIENT/FAMILY
DISCUSS WITH ATTENDING PHYSICIAN WHEN POST-DISCHARGE NEEDS CAN BE CLEARLY IDENTIFIED
REFER TO SOCIAL WORKER/IN-PATIENT CASE MANAGER AS APPROPRIATE
ALL INTAKE INFORMATION SHOULD BE COMMUNICATED WITH THE IN-PATIENT CASE MANAGER SO THAT A SMOOTH TRANSITION CAN TAKE PLACE FROM THE PRE-ADMISSION TO IN-PATIENT SETTING
A PRE-ADMIT NOTE SHOULD BE PLACED IN THE MEDICAL RECORD
EMERGENCY DEPARTMENT CASE MANAGEMENT
ROLE FUNCTIONS:1. GATEKEEPER
SCREEN ALL ED PATIENTS FOR APPROPRIATENESS OF ADMISSION
OFFER ALTERNATIVE CARE SETTINGS INITIATE CONTACT WITH ADMITTING MD
(ED ATTENDING AND PMD) PROVIDE CLINICAL AND PAYOR INFO TO
MD
ROLE FUNCTIONS: 2. FACILITATE INITIATION OF CARE
1. ON TREAT AND RELEASE PATIENTS2. ON ADMITTED PATIENTS3. ON OBSERVATION PATIENTS
EXAMPLES OF INITIATION OF CARE
ADMINISTRATION OF MEDICATIONTESTS AND PROCEDURESCONSULTSOBTAIN RECORDS FROM OUTSIDE
OFFICES/INSTITUTIONSOFFER ED DISCHARGE PLAN (HOME
CARE SERVICES)
3. START INTAKE/UTILIZATION PROCESS
DATA COLLECTIONASSESS CURRENT LIVING
SITUATIONOBTAIN INFO REGARDING
INFORMAL AND FORMAL SUPPORTSLAB AND ANCILLARY TEST RESULTS INITIATION OF TREATMENTS
4. ENCOURAGE USE OF REIMBURSABLE DIAGNOSES
PNEUMONIA VS PNEUMONIA WITH RESP FAILURE REQUIRING MECHANICAL VENTILATION, SEPSIS
CHEST PAIN VS UNSTABLE ANGINA, R/O MI
ABDOMINAL PAIN VS GALL STONE PANCREATITIS
R/O SEPSIS VS CLINICAL SEPSIS
OTHER ROLES
INTERFACE WITH COMMUNITY AGENCIES
CREATE PLANS FOR HIGH UTILIZATION PATIENTS
REFER PATIENTS TO OTHER/MORE APPROPRIATE HOSPITAL AREAS
MONITOR AND MANAGE VARIANCES
COMMUNITY AGENCIES
HOME CARE AGENCIESSENIOR CITIZEN CENTERSDAY PROGRAMSPOLICE DEPARTMENTNURSING/ADULT HOMESPROTECTIVE SERVICES (CHILDREN
AND ADULTS)
START DISCHARGE PLANNING ON ADMITTED PATIENTS
SPEAK WITH AMBULANCE STAFF MEET WITH FAMILY/FRIENDS INTRODUCE IDEA OF HOME CARE OR
OTHER ALTERNATIVE SERVICES INTERFACE WITH IN-PATIENT CASE
MANAGERS CHECK THAT PATIENT HAS A PRIMARY
CARE PHYSICIAN THAT THEY ARE COMFORTABLE WITH
HIGH UTILIZATION PATIENTS
IN ED AT LEAST ONCE EVERY THREE MONTHS
MUST CREATE PLAN WITH ED STAFF AND PMD (IF PT HAS ONE)
DETOX/REHAB PROGRAMS, SNF, GROUP HOME
HELP OBTAIN MEDICATIONS WAIT THE SITUATION OUT
(ALZHEIMER’S) NO MEALS/SHOWERS/CLOTHES/MONEY CONSISTENT APPROACH
OTHER HOSPITAL AREAS
DIRECT ADMISSIONAMBULATORY SURGERYCANCER CENTERELECTIVE PROCEDURES
(ENDOSCOPY)OTHER SPECIALTY AREAS
REFERRALS- FINDING PATIENTS
TRIAGE NURSE – EMS, POLICESTAFF – RN, MD, SW, PMD, CLERKS IN-PATIENT CASE MANAGERSFAMILY, FRIENDS, NEIGHBORS OF
THE PATIENTCOMMUNITY AGENCIES
INTEGRATING CM AND SOCIAL WORK: SHARED RESPONSIBILITIES
REFERRALS TO HOME CAREREFERRALS FOR DETOXTRANSPORTATION ISSUES OF NONCOMPLIANCE
INTEGRATING CM AND SOCIAL WORK:ISSUES OF NON-COMPLIANCE
CASE MANAGEMENT PT EDUCATION;
ASSESS FOR KNOWLEDGE DEFICIT, MEDS, FOLLOW-UP APPTS
SOCIAL WORK REFUSAL TO ACCEPT
NEEDED SERVICES LEAVING AGAINST
MEDICAL ADVISE CRISIS
INTERVENTION: SUBSTANCE ABUSE, FAMILY DYSFUNCTION, COPING WITH ILLNESS
INTEGRATING CM AND SOCIAL WORK: ISSUES OF PAYMENT
CASE MANAGEMENT QUESTIONS ABOUT
INSURANCE COVERAGE
SOCIAL WORK ENTITLEMENTS(MEDICAID,
DISABILITY, AIDS SERVICES, FOOD STAMPS)
COMMUNITY SERVICES (HOUSING, RED CROSS)
INTEGRATING CM AND SOCIAL WORK: OBTAINING MEDICATIONS
CASE MANAGEMENT ASK MD TO
PRESCRIBE LEAST COSTLY DRUG
ASK HOSPITAL PHARMACY TO GIVE MEDS
VOUCHER SYSTEM WITH LOCAL PHARMACY
SOCIAL WORK REFER FOR
ENTITLEMENTS HELP PT NEGOTIATE
PAYMENT PLAN WITH LOCAL PHARMACY
EXPLORE OTHER OPTIONS (VA HOSPITAL)
VOUCHER SYSTEM WITH LOCAL PHARMACY (SHARED FUNCTION)
INTEGRATING CM AND SOCIAL WORK:HOMELESS PATIENTS
CASE MANAGEMENT SHELTER REFERRALS
SOCIAL WORK SOCIAL HISTORY FINANCES CONTACT
FAMILY/FRIENDS COMMUNITY
AGENCIES
PURE SOCIAL WORK ISSUES
ISSUES OF CHILD ABUSE AND NEGLECT ISSUES OF DOMESTIC VIOLENCE, ELDER
ABUSE, SEXUAL ASSAULT, INSTITUTIONAL ABUSE
COUNSELING IN RESPONSE TO DEATH, TRAUMA, ACCIDENTS, INJURIES
CRISIS INTERVENTION LEGAL CONCERNS (GUARDIANSHIP)
CASELOADS AND COVERAGE HOURS
AT A MINIMUM COVER PEAK VOLUME TIMES IN THE ED
CONSIDER STAGGERING THE HOURS OF THE SOCIAL WORKER AND NURSE CASE MANAGER FOR MAXIMUM COVERAGE
NUMBER OF STAFF WILL DEPEND ON THE:– ED VOLUME– PAYER MIX– ADMISSION VOLUME
MEASURING SUCCESS
DECREASE IN COMMERCIAL ADMISSION DENIALS ND RAC DENIALS RELATED TO 2 MIDNIGHT RULE
REDUCTION IN READMISSIONS DECREASE IN ED LOS IMPROVED PATIENT SATISFACTION IMPROVED PHYSICIAN SATISFACTION DECREASE IN NUMBER OF ‘HIGH
UTILIZATION’ PATIENT VISITS DECREASE IN INPATIENT LOS
REDUCE ADMISSION DENIALS
COORDINATE 2 MIDNIGHT RULE PROCESS ASSURE MEDICAL NECESSITY ON NON
MEDICARE PATIENTS PROMOTE ACCURATE DOCUMENTATION DISCUSS TREATMENT AND DISCHARGE
PLAN WITH MD CONDUCT PHYSICIAN EDCUATION
INCLUDING COMMUNITY RESOURCES AND OTHER OPTIONS
REDUCTION IN READMISSIONS
REVIEW PATIENTS IN ED WHO HAVE BEEN DISCHARGED WITHIN 30 DAYS OR LESS
CONSIDER ALTERNATIVES TO READMISSION WITH THE PHYSICIAN
WATCH FOR PATTERNS BY:–ADMIT SOURCE–MD
DECREASE IN INPATIENT LENGTH OF STAY
EARLY INTERVENTION = QUICKER PROGRESSION OF CARE = EARLY DISCHARGE
MAKE THE BEST USE OF THE TIME THE PATIENT SPENDS IN THE ED
TESTS ORDERED FROM THE ED ARE OFTEN GIVEN PRIORITY OVER THOSE ORDERED FROM AN IN-PATIENT UNIT
IMPROVE PATIENT SATISFACTION
KEEP THE PATIENT INFORMEDEXPEDITE TESTS AND PROCEDURES INFORMATION GATHERING BY THE
ED CM IS OFTEN PERCEIVED AS ‘CARING’ BY THE PATIENT/FAMILY
IMPROVE PHYSICIAN SATISFACTION
NOTIFY THE PRIMARY CARE PROVIDER THAT THEIR PATIENT IS IN THE ED
RE-NOTIFY THEM IF THE PATIENT IS ADMITTED
GATHER RELEVANT HISTORY ON THE PATIENT
DECREASE LENGTH OF STAY IN THE ED
ANTICIPATE ED DISCHARGESMEET PATIENT’S FAMILY, FRIENDS
OR CAREGIVERS EARLY IN ED STAY IDENTIFY AND COMMUNICATE WITH
COMMUNITY RESOURCES IN PLACE AND/OR AVAILABLE TO THE PATIENT
MAKE SOCIAL WORK REFERRALS
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