Care Management Can We Do It Better?

Transcription

1 Care Management Can We Do It Better? Wilma Acosta, Associate Director Protiviti, Inc. Alex Robison, Managing Director Protiviti, Inc. Agenda I. Care Management Challenges II. Compliance Case Studies Intermittently throughout Presentation III. Audits Methods Traditional vs Innovative IV. Care Management Models Considerations for Future State Workflows, Department Configurations V. Discussions Q&A 3/13/ CARE MANAGEMENT Data Analytics for New Model PAYOR INTERVENTIONS PATIENT NURSING & SOCIAL SERVICES PHYSICIAN DATA REAL TIME Real Time Alerts & Enhanced Communications Team approach CM is part of nursing rounds Interventions for high risk populations to reduce inappropriate patient status admits Data Analytics for timely interventions 3/13/

2 Care Management Payors World Payors Medicare/Medicaid and other Federally Funded programs coverage and payment methods dictate patient bed status No two exact default to CMS Medicare Manual But should this be the Norm? What about ACOs, Managed Care and Employer Plans,? 3/13/ Care Management Challenges Challenges Clinical and Regulatory InterQual and Milliman Criteria Local / National Coverage Determinations (LCDs) (NCDs) Physician Advocate / Advisors 2 midnight Rule Observation 1 day stays Outpatient in a bed Condition code 44 3/13/ Case Study #1 Health system A ( HS A) with large oncology services admits a patient for inpatient chemotherapy. HS A obtains pre admit approval from Medicaid for 2 days inpatient chemo infusion therapy. Reason: patient had difficult time with chemo severe reaction and requires monitoring for uncontrolled Nausea / Vomiting / Dehydration. Upon external audit review, the reviewer determined this patient should not have been admitted as inpatient but instead placed in observation. Case Denied for 1 day stay. Which of the following do you think was the cause of the denial? Patient tolerated chemo, stable no major reactions noted on next day. Patient s history of difficulty with chemo therapy, and family social issues noted by physician as reason for admission. Discharge patient had no unusual chemo reactions, stable and able to go home noted on same day of chemo. 3/13/

3 AUDIT METHODS TO DO OR NOT TO DO? 3/13/ Traditional Audit Processes Typically, review x number of charts A selection of 1 day stays and observations Policies and procedures are reviewed Claims reviewed Findings are provided to case management compliance not generally included 3/13/ Traditional Audit Processes General Recommendations: Use CMS Medicare Inpatient Only List Know InterQual and Milliman Know CMS rules regarding observation criteria Employ physician advocate, e.g. Executive Health Resources, Accretive, Use Condition 44.carefully Have CMs in Emergency Room & weekend coverage But upon Follow up no major changes! Lack of Changes, Controls or Improvements Risk of repayment and Focus review same or increased. 3/13/

4 Traditional Audits Revealed CMs do not asses potential admission within 4 6 hours of arrival to hospital Cases were not reviewed by payor type First come/ First Served therefore an observation order may not be timely obtained 24 hour coverage in key patient areas, Emergency, Post op recovery, were not supported by schedules or actual staffing CM performing clerical / Admin duties Social Service Workers were not part of the interdisciplinary team in Emergency Department, they were not handling the complex social issues 3/13/ Audit To Think Out Of The Box! Create a new audit process with compliance involved Identify what did not yield long term sustainable results o Chart to claim audit not sufficient o Evaluation of care management tools not sufficient o More forms or staffing not sufficient Consider The 3 W s of Auditing Care Management o What to review o Who to review o When to review 3/13/ New Audit Concept What: Patients in Emergency, Outpatient Surgical Areas, Cath Lab, Interventional Radiology, Pre op Systems utilized for CM e.g. InterQual, Midas, Forms and clinical policies, orders, Who Staff competencies Physician Advisor / Advocate process ED Chief, PACU Chief, Post op Recovery Nurse Director When Review the entire CM process from time patient enters system to patient final disposition / discharge Round / Shadow / Observe evenings, weekends with CM team 3/13/

5 New Audit Concept cont. Observe CM real time in the actual departments where patients first enter the hospital Emergency Room (ED )Outpatient procedures; such as Interventional Radiology, Cath Lab, Post Op Recovery, Endoscopy, Infusion Center, Day Surgery Shadow the CMs during peak times weekend and late evenings Interview Surgery Scheduler(s) for use of Medicare Inpatient Only List Interview the Physician Advisor (phone interview if external) 3/13/ Compliance Gets Involved Compliance should have role in the development of training materials Compliance should be the final reference source for CMS rule interpretations Set the definitions of observation, 2 midnight rule, etc Write the education for the Care Managers Provide interpretation of rules and regulations for consistency Do Not Let Care Management Director Interpret Medicare Language! 3/13/ Compliance Gets Involved Be notified when Care Management reviews denials of patient status. Approve the change / write the standards for changing the patient status to obtain payment Know the workflow and processes and monitor frequently Ensure clinical Care Management has competent staff 3/13/

6 Case Study #2 Emergency room of a Trauma I center, it is Saturday morning, 8:30am, the CM is sent to 6 th floor to cover med surgical unit. No CM was left to cover the Emergency Dept. 2 patients in behavioral health crisis arrived 10:05am, 10 year old with severe 10:35, and 3 MVAs Trauma 1 arrived in ER within 10 minutes of each other around 11:30, meanwhile there were 3 patients awaiting bed placement and no observation orders. Key to know that 2 of the MVAs and the 3 awaiting bed placement were Medicare and Medicaid patients. What should hospital do, since the CM is also the UR coordinator for the day and must handle the discharges and backlog of patients in 1 and 2 day stays and those already in Observation > 48 hours? 3/13/ MODEL SOLUTIONS 3/13/ CM MODEL Emergency Dept. CM works from a central location in the ED assessing and reassessing all arrivals to ED focusing first on Medicare and Medicaid patients. Emergency Room Care Manager Assess new arrivals to ED with 2 4 hours Reassess all ED patients in a bed > than 8 10 hours Covers outpatient surgical and interventional areas Discharge Plans for outpatients in a bed = < 24 hours 1 day Stays and Condition Code 44 & Assess Readmissions Manages all Medicare and Medicaid admits in first 24 hours 3/13/

7 UR Centralization Model UR works remotely or from a central location in the hospital managing cases not requiring daily review/assessments, back up for CM staff and serve as super users. Centralized Utilization Review OBS > 48 hrs & 10 Day LOS Review Readmissions Denials related to patient status Discharge Plans for inpatients > 24 hours Inpatient Surgeries, Pediatrics, General Medical Inpatient > 24 hours Condition Code 44 backup Super Users Train new staff Coverage 3/13/ Support Centralization Model In this model UR Support works remotely or from a central location in the hospital supporting all CM/UR staff and serve as super users. * Care Support LPN, Nurse Aid, Unit Clerk Transportation Arrangements (Taxis, vouchers, ambulances) DME/Therapy Scheduling Manage return calls from Insurance Companies Calling/Faxing/E mails for information on available services as directed by UR/LSW Assist patients/families with forms and placement or discharge processes 3/13/ CM Model for Clinical Units Care Manager Rounds with Medical Team in unit Assesses Patient Status Determinations Reviews Direct Admits Reviews Observation cases > 24, and evaluates for potential 2 night midnight admits Recognizes and Performs Condition Code 44 procedures Completes Concurrent Reviews & 1 Day Stays Begins Discharge Plan (Identify type, handoff to LSW) 3/13/

8 Use concept maps to plan CM care History/ Comorbidities Diagnostics patient Labs Skilled Therapies Medications Treatments 3/13/ Model Reporting Structures 3/13/ Potential New Organizational Reporting Structure Options CMO UR committee UR Nurses Revenue Cycle Utilization Manager LSWs CFO Clerical Care Support Staff In this structure Care Managers and UR Managers are separate and UR Managers report in to Revenue Cycle. They have a dot matrix to Quality and CM. They handle medical necessity denials, and work patient status remotely. 3/13/

9 Additional Organizational Reporting Structure Options CMO CFO Quality Committee CDI Director, Quality VP Quality/Care Management Quality Analyst Care Manager CMs, UR, & LSW UR committee In this structure Care Management reports up through the CMO with a direct dot matrix to the CFO. This centralizes the reporting but separates it from Quality and causes a financial accountability 3/13/ Systems and Tools Evidence based, decision support criteria from Milliman, InterQual and others are an essential part of any UM program to help determine the right care. Managed guidelines for conditions, particularly where there is wide practice variation, present a means of increasing cost effectiveness while improving outcomes across the board. Case management software applications must provide case managers with easy access to information, enhanced documentation, and improved accountability. 3/13/ Systems and Tools The application needs to be integrated with other sources of patient information, (i.e., claims, lab results, medications, health risk assessments, UM and DM data, etc.), so all the data needed for decision making is available in one integrated system real time. Based on this information and built in business rules, the application should be able to automatically present appropriate care options to the case manager, so he/she can develop individualized care plans that meet the unique needs of each pat 3/13/

10 Excerpt from St. Luke s job description Provides clinically based CM to support the delivery of effective and efficient patient care. Has overall accountability for the UM and discharge plan for pts. within the assigned caseload. Collaborates with members of the health care team to identify appropriate utilization of resources and to ensure reimbursement. Utilizes criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, creates a discharge plan appropriate to the patient s needs and resources. 3/13/ critical care physicians. CM Specialists 3/13/ Inform Patients of the CM Program Web Site HOME FOR PATIENTS & FAMILIES Preparing for a Visit Find a Doctor Visitor Information Contact Us Care Management Pastoral Care Suites and Single Rooms Room Service Enrolling in Clinical Studies Insurance Information > Departments & Services > Education & Prevention Programs Care Management At St. Francis Hospital, a team of nurse Care Managers and Social Workers will help plan and assess your care needs before you leave the hospital. Social Workers Social Workers at St. Francis provide post hospital information and referrals, crisis intervention and supportive counseling services. Your Social Worker can help ease your transition after your hospital discharge and offer referrals for community resources to assist in finding alternative care and managing illness. Care Managers Care Managers at St. Francis develop and coordinate your continued care services. Such services might include referrals to home care, rehabilitation, IV home infusion, Meals on Wheels and other post hospital resources. Your Care Manager will research your needs and insurance coverage to find the available and appropriate services for you. For more information, call the St. Francis Care Management Department at , Monday through Friday, from 8 a.m. to 6 p.m., and from 8 a.m. to 4 p.m. on weekends and holidays. 3/13/

11 Inform Patients of the CM Program Web Site Cleveland Clinic Care Management While you are a patient at Medina Hospital our primary goal is to speed your return to good health. As our experts respond to your medical needs, we know that meeting your social, financial, emotional and environmental needs can also contribute to your recovery process. Care Management is a key resource in meeting those needs. Care Management Staff Our caring staff combines the skills of nurses, social workers and insurance reviewers (utilization review) to assess the patient s needs. These individuals work closely with the patient, family, physician and healthcare team. Staff is assigned to specific nursing units. All inpatients and observation patients are reviewed at the time of admission to ensure they meet inpatient admission criteria. Patients are continually reviewed throughout their hospitalization to ensure they are discharged to the appropriate setting, at the appropriate time. Discharge Planning An essential part of your post hospital care is discharge planning. Considering these plans early helps to alleviate later stress as you recover. Medina Hospital social workers have a primary role in the development of this discharge plan. We can help you design a post hospital care plan tailored to your specific needs. Providing Resources Counseling/Rehabilitation Services Our social workers can link patients and their families to: Support Groups Home Healthcare Legal Services Homemaker Services Meal Programs Medical Equipment Financial Assistance Programs Day Care Programs Nursing Home Placement locations/medina hospital/guestservices/care 3/13/ Two Midnight Rule And Other New Guidance 3/13/ Two midnight rule controversy Delayed to Oct 2014 Kenneth Raske, president of the Greater New York Hospital Association, sent a letter to members informing them of the update. He said it was "welcome news," but "the fact remains that the two midnight policy still stands, and GNYHA continues to support legislation to create an appropriate payment mechanism for short inpatient stays." CMS has delayed the two midnight rule through Sept. 30 after fierce opposition came from hospitals, physicians and other healthcare groups. The two midnight rule is a new regulation included in the 2014 Medicare inpatient prospective payment rule. The policy established that inpatient admissions spanning at least two midnights qualify for Medicare Part A payments. Inpatient stays lasting fewer than two midnights must be treated and billed as outpatient services. According to a CMS update, the enforcement of the two midnight rule will not begin until this October. This means Medicare administrative contractors and recovery auditors will not conduct two midnight post payment reviews of claims with admissions dates between Oct. 1, 2013, and Oct. 1, MACs and RAC will carry out prepayment reviews of hospital admissions that occur between March 31, 2014, and Sept. 30, Depending on the hospital, auditors will review 10 to 25 claims per facility. 3/13/

12 Long stay observation cases increased from 3% of all cases in 2006 to 8% in The decision to admit a patient should be based on an expectation that the patient will require at least a two midnight stay. CMS contractors will operate under the presumption that stays of at least two midnights are medically necessary, with the clock beginning when the patient starts receiving hospital services (including observation services). During the September 26 open door forum, CMS clarified that if a patient stays one midnight in observation and the physician expects that the patient will require at least another midnight in the hospital, the patient can be appropriately admitted despite the fact that it is a one day inpatient stay. If a patient is admitted but ultimately doesn t stay two midnights, clear physician documentation supporting the order and expectation of two midnights will be required. 3/13/ CMS announced an amnesty period on reviews from Oct. 1 to Dec. 31. CMS essentially has announced an amnesty period on reviews from October 1, 2013 to December 31, RACs will not review cases during this period Medicare administration contractors will only review cases with a length of stay less than two midnights Opportunity to change how and when patient status is determined Opportunity to decrease medical necessity denials due to patient status Opportunity for compliance to insert itself in Case Management processes that would decrease observation and 1 day stay issues. 3/13/ Discussion & Questions 3/13/

13 Thank You! Wilma Acosta, RN, BS, CHC, CPHQ Associate Director Protiviti /13/