CHANGING YOUR CASE MANAGEMENT MODEL OF CARE. Jan Lear, RN, CMC Director of Case Management MedStar Franklin Square Medical Center

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1 CHANGING YOUR CASE MANAGEMENT MODEL OF CARE Jan Lear, RN, CMC Director of Case Management MedStar Franklin Square Medical Center 1

2 Program Objectives To be able to describe the compliance and regulatory knowledge of Medicare and Medicaid Program that impacts case management To be able to explain the difference between the Dyad and Triad models for case management To be prepared to use data and develop a workflow tool that will determine the skill mix and outcomes needed to meet future needs of your case management department 2

3 Case Management Reimbursement and Regulatory Challenges RAC/MAC Audits Hospital Condition of Participation Readmissions Observation Important Message InterQual Condition 44 Face to Face Form PEPPER Report 3

4 Reimbursement and Regulatory Challenges RAC/MAC Changing the Reimbursement of Your Hospital Impact on Your Appeal Department Each Denial Has The Capacity to be Handled Five Times Pre-Payment Audits - Hips and Knees PEPPER Report Hospital Condition of Participation Readmissions Discharge Planning Utilization Review UR Committee Code 44 Admission Status, Level of Care LOS - Outliers Multi-Disciplinary Team Transitional Care Nurses - New Relationships with Sub Acute Facilities, Home Health Agencies, PCP ED Presence return to Sub Acute or HHA 4

5 Reimbursement and Regulatory Challenges Inpatient vs Observation Other Correct admission status Calculating the hours Complete physician orders Condition Code 44 Observation Letters InterQual and Milliman Criteria Potentially Preventable Complications Important Message Face to Face Form 5

6 CMS announces official start date for Recovery Auditor prepayment reviews Hospitals put 7-figure price tag on readmission penalties Observation stays may hurt some patients Boston Teaching Hospital fined $ 1.5M for ephi data breach 6

7 Case Management Department Case Managers Case Management Department Social Workers Deliver Highest Quality Care at Lowest Costs Utilization Review Denials/Appeals Clinical Documentation Core Measures 7

8 Dyad Model of Care Care Coordination Discharge Planning Utilization Review 8

9 Case Managers Utilization Review Social Workers CM/SW Shared Responsibilities Care of Medically Complex Patients Resource Management Discharge Planning- Medical Complex Patients Core Measures Outcomes Interdisciplinary Rounds Medicare Discharge Appeal Letters Medical Necessity of Admissions 100% of admissions Clinical Review Appropriate Admission Status and Level of Care Orders are Written Correctly Retrospective Appeals Condition 44 Readmissions Prevention of Denials/Appeals Performs Psycho-Social Assessments Guardianship, Ethical or Legal Concerns Financial Assessments Self Pay- Uncomp, Homeless Substance, Elder, Child, Domestic Abuse Adoption, Homeless, Transportation, Advance Directives, End of Life, Crisis Intervention Discharge Planning Important Message Face to Face Form for Home Health 9

10 Triad Model of Care Care Coordination Discharge Planning Utilization Review Utilization Review Nurse 10

11 Case Managers Social Workers Utilization Review Denial Management Coordination of Care Resource Management Discharge Planning- Medical Complex Patients Core Measures Outcomes Management Interdisciplinary Rounds Medicare Discharge Appeal Letters Performs Psycho-Social Assessments Guardianship, Ethical or Legal Concerns Financial Assessments Self Pay- Uncomp, Homeless Substance, Elder, Child, Domestic Abuse Adoption, Homeless, Transportation, Advance Directives, End of Life, Crisis Intervention Medical Necessity of Admissions - 100% of Admissions Clinical Reviews Appropriate Admission Status and Level of Care, Orders are Written Correctly 3808 s Appeals Payor Specialist Concurrent Management of Denials RAC/MAC Resource Department Transportation Interpreter Services Supplies 11

12 Future Decisions What Data do I Need? What Skill Mix Do I Need? What Outcomes Do I Want? 12

13 Data Elements Total Admissions Inpatient Observation ED Visits Payor Mix LOS Case Mix Index Social Interventions Denials Initial Assessment Discharge Planning UR Functions 13

14 Care Coordination FY 2012 Total % Inpatient Versus Observation FY 2011 Total % Inpatient Versus Observation Admissions Inpatient 16,569 79% 16,031 83% Observation 4,410 21% 3,363 17% ED Visits 66,375 68,327 14

15 Care Coordination Current YTD Actual Percentage Of Total Admissions Prior YTD Actual Percentage Of Total Admissions LOS Less then 1 day 847 4% 808 4% One Day 5,273 25% 5,042 26% Two Days 5,384 26% 4,919 25% Three Days 3,560 17% 3,129 16% Over three days Total Admissions 5,813 28% 5,411 29% 20,877 19,309 15

16 Care Coordination Current YTD Actual % of Total Admissions Prior YTD Actual % of Total Admission s Patient Assessments 7,950 38% 7,792 40% D/C Planning Notes 23,024 22,619 Problem Notes 57,832 44,122 Total Admissions 20,877 19,309 16

17 Psycho Social Interventions Current YTD Actual Prior YTD Actual Total Psycho Social Interventions 4,586 5,776 Assessments 1,763 1,696 Family Meetings Advance Directives Hospice Placement Insurance Issues Substance Abuse Abuse/Neglect

18 Utilization Review Current YTD Actual Prior YTD Actual Top 5 Payors Medicare 7,783 7,045 Med Star Family 1,338 1,305 Blue Cross 1,819 1,377 Self Pay Medicaid Pending

19 Utilization Review Current YTD Actual Prior YTD Actual Correct Status, Level of Care Observation Charges MCR Reviews For Correct Status (Every 3 days) 20,979 19,394 4,410 3,363 7,783 7,045 19

20 Commercial - Denials and Appeals Current Total # Claims Prior Total # Claims Current YTD Actual Prior YTD Actual Current Total Dollars Prior Total Dollars Denied Days ,229 1,374 $1,702,054 $1,522,603 Overturned Days $395,154 $351,283 20

21 RAC - Denials and Appeals June 2011 to Current Total # Claims Open Closed Current Total Dollars at Risk Total Dollars Overturned Percentage Overturned Round One $215,713 $44,460 21% Round Two $189,002 $67,654 36% Round Three $129,375 $71,829 56% Round Four $234,756 0 Total $768,846 $183,943 24% 21

22 MAC - Denials and Appeals Current Total # Claims Appealed Not Appealed Overturned Current Total Dollars at Risk Total Dollars Overturned $379,817 $25,408 22

23 Readmissions Feb Current All Admissions Current FY Readmissions Percentage Prior All Admissions Prior FY Readmissions Percentage All 16,345 1,741 11% 16,621 2, % CHF % % COPD % % 23

24 MFSMC Readmission Rates FY 11 July Aug Sept Oct Nov Dec Jan YTD 11.2% 10.4% 11.6% 10.5% 9.8% 10.6% 10.2% 9.9% 10.4% 24

25 Work Flow Tool Chemical Dependency Assessment Advance Directive Family Meeting Guardianship Psych Placement Homeless Requesting Intervention Frequent Admissions Domestic Violence Death Foster Care Social Worker Work Flow Tool End of Life Locating Family Members Medication Assistance Cultural or Language Issues HIV Resources Insurance Issues No Prenatal Care Follow -up 25

26 Nurse Case Manager Work Flow Tool Completing UR s Specialized DME BiPAP/CPAP Medications - Antibiotics Medications Coagulation TPN Insurance Issues- Medical Necessity Family Meetings Radiation Therapy Specialized DME Wound VAC Assessment Acute Rehab Ventilator Placement Patient Complaint Home Care KePro Level of Care Transfer to Another Hospital Specialized DME Specialty Beds Outpt Dialysis 26

27 Work Flow Tool Level One Level Two Level Three Level Four Any intervention that lasts 15 minutes or less Any intervention that lasts minutes Any intervention that lasts minutes Any intervention that lasts over 60 minutes Requires a narrative note 27

28 Skill Mix Case Manager Social Worker Documentation Specialist Appeal Nurses Utilization Review Nurses Transitional Care Nurses Type of Units Types of Services Provided Inpatient /Outpatient Patient Types Volumes Outcomes/Goals 28

29 Thank You Any Questions? Telephone

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