Using a Case Management Process in the care for the Undocumented Mexican National
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1 Using a Case Management Process in the care for the Undocumented Mexican National Presented by Pam Manning, RN, BA, ACM Manager, Case/Utilization Management University of Colorado Hospital Denver, Colorado GATEWAY TO LATIN AMERICA
2 University of Colorado Hospital Case Management Model Collaborative team model Case/Utilization Manager, RN Social Worker Home Health Coordinator, RN Unit based and Service based Carve outs for medicine, cardiology, CT surgery Skill Sets required for the team Clinical expertise Cultural competency Good Counseling skills Access to interpreter services Gateway to Latin America 1
3 Case Management Process Initial High Risk Assessment key to process Who: patient demographics What: admitting diagnosis Where: point of entry for the admission Why: does the patient need case management services When: identify anticipated discharge date How: Who: will the hospital be re-imbursed for the care does the patient have a support system, decision maker Gateway to Latin America 2
4 Who is the patient? Challenges for the Care team Identity is not always known: john doe, no ID found Name is not always accurate: often have a hyphenated name, spelling challenges No permanent address: live with a friend, apt on the corner of 11th/Colfax, can t remember phone number Social Security # provided but not valid Contact information: can t remember phone number, no response at home, family in Mexico VALIDATION: UNDOCUMENTED MEXICAN NATIONAL Gateway to Latin America 3
5 What is the diagnosis / anticipated discharge date? Often trauma related Assault with multiple trauma Hit and Run victim Spontaneous head bleed Admitted to ICU High costs during first few days of admission: ventilator support, imaging, labs, multiple drips for sedation & pain control, antibiotics, dialysis, etc. Discharge date unknown but based on diagnosis, treatment plan, often involves an extended length of stay Gateway to Latin America 4
6 Where was the point of entry? Most often come in through the Emergency Room via ambulance / 911 Transferred for higher level of care, specialty services Frequent flyer to ER due to no insurance, no Primary Care Provider Gateway to Latin America 5
7 Why are case management services needed? ICU admission should trigger automatic high risk assessment Demographic / contact information incomplete and/or inaccurate Insurance issues Life threatening diagnosis Family support / counseling needs Gateway to Latin America 6
8 How is the hospital reimbursed? Self pay status Little chance of receiving any payment Medicaid Emergency only Qualifications must be met 12 month disability 30 day continuous hospital stay Payment for inpatient admission only No funding available for: LTAC,SNF, NHP, DME, follow-up clinic appointments Gateway to Latin America 7
9 Who is the support system? Family members often remain in Mexico as patient working in United States and sends money back home Language barriers often Spanish-speaking only No official resident often here working and living with friends / extended family members Friends uncomfortable with decision making issues Gateway to Latin America 8
10 Ethical / Legal Barriers Opinions related to the care are vast Why keep providing all this expensive care when we won t see a penny in return? We should be able to bill Mexico Can t we just drive them to the border and drop them off? Mexico hospitals can t care for this type of patient Patient is being kicked out of the hospital because he/she is from Mexico and has no insurance We have spent all this time and money lets just continue Gateway to Latin America 9
11 Ethical & Legal Barriers PRO CON Gateway to Latin America 10
12 Discharge Planning Challenges Summary of DC Issues: Long length of stay High use of resources No payer for placement Require 24/7 care Language / Culture pressure from MD s to discharge patient Family in Mexico Find hospital / MD in Mexico Consult help = involved & lengthy process Still have financial implications Gateway to Latin America 11
13 Discharge Planning Solutions Discuss all possible discharge solutions with patient, family, friends Local home available? Self pay for all therapies, follow-up care, DME, supplies 24/7 care most likely required No alternative placement options due to lack of funds Gateway to Latin America 12
14 MexCare An alternative choice for the care of the unfunded Latin American National Gateway to Latin America 13
15 What is MexCare? A network of hospitals and physicians in Latin America Offer placement in facilities closer to patients home Significant reduction in the cost of unpaid services Gateway to Latin America 14
16 MexCare Services MexCare contacts patient / family to discuss hospital placement based on required care and family location Develop a plan for transfer, care and discharge Coordinate bed to bed transfer Gateway to Latin America 15
17 Make referral to MexCare Provide Clinical Documentation Obtain proposal Coordinate bed to bed transfer Agreed upon care plan Cost per day to include all services required Transportation Discharge day Gateway to Latin America 16
18 Administration Approval Process Review Bill to Date Analyze cost/day Estimate continued LOS for patient Cost comparison between patient remaining in hospital versus outsourcing care with MexCare Capacity Management / Throughput issues Gateway to Latin America 17
19 Patient Profiles Patient A: 41 year old male Diagnosis: Intra cranial hemorrhage, craniotomy, multiple complications Admitted 11/27/05 Discharged 04/10/06 Total charges: $1,0677,184 (as of 3/30/06) Using cost to charge ratio: $2,400 cost/day Discharge Needs: continued acute medical needs, rehab, follow-up care; Support System: wife in CO, family in Mexico Outsourced to MexCare: $75,800 (reimbursed $5,650) $650/day (vent) x 90 days = $58,500 Air Ambulance $17,300 Medicaid (Emergency) approved & paid: $120,486 December 2006 Gateway to Latin America 18
20 Patient Profiles Patient B: 52 year old male Diagnosis: Anerusym s/p clipping, pleural effusions s/p VATs Admitted 6/08/06 Discharged 08/15/06 Total Charges: $719,725 Using cost to charge ratio: $4,153 cost/day Discharge Needs: SNF, medication management, 24/7 care Support System: ex-girlfriend in CO, estranged family in Mexico Outsourced to MexCare: $36,950 $450/day x 60 days= $27,00 Air Ambulance (split with Patient C): $9,950 Medicaid (Emergency) not approved, $0 reimbursed Gateway to Latin America 19
21 Patient Profiles Patient C: 22 year old male Admitted 7/9/06 Discharged 8/15/16 Diagnosis: SAH s/p severe assault to head, craniotomy, multiple orbital fractures, Total Charges: $317,476 (as of 8/4/06) Using cost to charge ratio: $2,637 cost/day Discharge Needs: continued acute medical needs include OR to replace skull bones, SNF, 24/7 care, Support system: involved extended family in CO, add l family in Mexico Outsourced to MexCare: $65,850 $450/day x 90 days = $40,500 Surgical fees for neuro / plastic surgery: $15,400 Air Ambulance (split with Patient B): $9,950 Medicaid (Emergency): not approved as over income $0 reimbursed Gateway to Latin America 20
22 Patient Profiles Patient D: 50 years old unknown john doe Diagnosis: Blunt abdominal trauma, cervical spine fracture, colon injury, multiple organ failure Admitted: 9/16/06 Discharged 11/11/06, Total Charges: 468, (as of 11/11/06) Using cost to charge ratio: $2,528 cost/day Discharge Needs: continued medical care, SNF, medication adjustment, nutrition f/u Support System: family in Mexico Outsourced to MexCare: $45,000 $450/day x 60 days=$27,000 Air ambulance = $18,000 Medicaid (Emergency): status pending approval / denial Gateway to Latin America 21
23 Lessons Learned Don t wait to explore outsourcing the continued care once patient is medically stable and safe to transfer to alternate setting, start the process! Communication / Education Key to success is buy-in by the medical team Begin dc planning options with patient & support system early on: Request updates on patient s condition and outcomes from MexCare, Keep Administration informed of patient, dc planning & options Gateway to Latin America 22
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