SDoH Recognized in the 2023 IPPS Final Rule

This article appeared on ICD10monitor.com on August 22, 2022

---

The Centers for Medicare & Medicaid Services (CMS) unveiled the fiscal year (FY) FY 2023 Inpatient Prospective Payment System (IPPS) Final Rule in early August.

The agency included a discussion about Social Determinants of Health (SDoH), defined as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health functioning, and quality-of-life outcomes and risks.” It is recognized that SDoH “influence an individual’s health status and can contribute to wide health disparities and inequities.”

They can be important risk factors in developing medical conditions like heart disease, diabetes, and obesity.

There is, however, a fundamental catch-22 regarding the documentation, coding, and recording of SDoH. In the big healthcare picture, they are very influential, but they may not be thought to affect the resource consumption during a hospital admission.

So why should hospitals invest the time and resources to capture SDoH data? But if hospitals don’t capture SDoH codes, we may not be able to identify how prevalent the conditions are in hospitalized patients. If we can’t recognize how frequently they occur and in which patients, we may not be able to appreciate their impact on the hospitalized patient. We can’t tell if those conditions have increased the length of stay or required significant social work or utilization review/case management planning if we are not recording and coding them.

Homelessness is a concrete example of this. It is one of the more commonly reported SDoH codes but it is still believed to be underreported. The Z59.0- category was recently expanded to include sheltered, unsheltered, and unspecified homelessness. Homelessness had been proposed (but tabled) to become a comorbid condition or complication (CC), but the calculation to determine whether it is CC-worthy is being impacted by underreporting of the condition.

The data of SDoH is important to collect for many reasons. There needs to be an incentive or a simple way to collect the data. One of the objections is that there is a limited number of diagnoses which can be entered on a claim, and folks are reluctant to use up some of those precious line-items on non-medical conditions. Comments were also made about the benefit of screening for SDoH if there is no mechanism to make referrals or to connect patients to resources to address their needs. There was also a concern that there may be a stigma associated with SDoH, and patients may be hesitant to share that information.

People are not familiar with all 73.5 thousand ICD-10-CM codes. They likely don’t know all the codes which are housed in the Z55-Z65 categories which comprise the SDoH. I am not sure the hospital personnel need be acquainted with or elicit every SDoH condition.

However, there is a list of SDoH conditions which I think are likely to be more impactful on the healthcare consumption and equity playing field. Here is my list:

• Z55.0 Illiteracy and low-level literacy

• Z56.0 Unemployment, unspecified

• Z57.1 Occupational exposure to radiation

• Z57.31 Occupational exposure to environmental tobacco smoke

• Z57.39 Occupational exposure to other air contaminants

• Z57.4 Occupational exposure to toxic agents in agriculture

• Z57.5 Occupational exposure to toxic agents in other industries

• Z57.6 Occupational exposure to extreme temperature

• Z58.6 Lack of adequate drinking water

• Z59.0- Homelessness

• Z59.41 Food insecurity

• Z59.5 Extreme poverty

• Z59.7 Insufficient social insurance and welfare support

• Z59.81- Housing instability

• Z59.82 Transportation insecurity

• Z59.86 Financial insecurity

• Z60.2 Problems related to living alone

• Z60.4 Social exclusion and rejection

• Z64.0 Problems related to unwanted pregnancy

CMS is still sorting this out, and I will be interested to see where facilities and providers end up landing on collecting SDoH data. I hope they figure out a time-efficient and standardized manner that does not create undue burden.

There may be a benefit not only to the individual patient, but also to the health system in general.

Programming note: Listen to Dr. Erica Remer every Tuesday morning when she cohosts Talk Ten Tuesdays with Chuck Buck at 10 Eastern.

SDoH at the Intersection of Skilled Nursing Facilities

This article appeared on RACmonitor.com on August 17, 2022.

---

EDITOR’S NOTE: This story comes at the request of Mary Beth Pace, vice president of care at Trinity Health. Her question last week arose out of the hospital three-day waiver for skilled nursing facilities (SNFs) during the public health emergency (PHE) waiver.

The PHE removed the required three-day inpatient stay for any hospitals struggling with a surge in patients as a result COVID. 

Just a reminder the PHE stated that “Using the authority under Section 1812(f) of the Act, CMS is waiving the requirement for a three-day prior hospitalization for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19” (CMS.gov, COVID-19 Emergency Declaration Waivers).

Now, what I saw early in the pandemic were SNFs that although, the PHE was in place, were unwilling to accept patients until the three-day stay was met for fear they would not be reimbursed by the Centers for Medicare & Medicaid Services (CMS). However, Mary Beth highlighted a new trend that required me to do some digging. I reached out to my trusty colleagues who are apart of health system ACOs across the country and we found a new discovery. Many of the SNFs were moving their long-term patients back into “skilled care” for additional reimbursement under the waiver without a hospitalization, let alone a three-day inpatient stay.    

Since many health systems are apart of an arrangement for their Medicare populations typically MSSP, they are indirectly responsible for the cost of care which also lends them to valuable data on their post-acute utilization. One health system, reported, a 20 percent increase in SNF utilization for patient stays with no preceding inpatient stay. The stays were also unrelated to COVID or a COVID related diagnosis for skilled care. Another colleague at a major health system in Texas also experienced this utilization issue and found that many SNFs had seen a drop in their skilled census and thus were using the waiver to “skill their existing long-term patients.” 

So, I would like to ask our listeners today if you are seeing similar trends. Are your local SNFs or is your health system seeing either SNFs not taking patients despite the waiver for the three-day stay or are they overusing this waiver by filling their beds with their existing patients to bill for a SNF stay?   

• Under utilizing the three-day SNF waiver

• Over utilizing the three-day SNF waiver

• Appropriate use of the three-day SNF waiver

• Unsure

• Does not apply

The responses from the Monitor Mondays listener survey may surprise you, and can be viewed here.

Programming Note: Listen to Tiffany Ferguson live reporting on the SDoH every Monday on Monitor Mondays at 10 Eastern.

References:

https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf

Enforcers Target Discharge Planners/Case Managers Yet Again

Copyright 2022

---

Case managers/discharge planners continue to come under fire from fraud enforcers for violations of the federal anti-kickback statute. This statute generally prohibits anyone from either offering to give or actually giving anything to anyone in order to induce referrals. Case managers/discharge planners who violate the anti-kickback statute may be subject to criminal prosecution that could result in prison sentences, among other consequences. 

Most recently, a U.S. District Judge in California sentenced an owner of a post-acute provider to eighteen months in prison for one count of conspiracy to commit health care fraud and one count of conspiracy to pay and receive health care kickbacks. From July of 2015 through April of 2019 the provider paid and directed others to pay kickbacks to multiple case managers/discharge planners for referrals of Medicare patients, including employees of health care facilities and employees' spouses. Recipients of the kickbacks included a discharge planner/case manager at a hospital, and discharge planners at skilled nursing and assisted living facilities.

Payments of kickbacks resulted in over eight thousand claims to Medicare for patients referred to the provider. Medicare paid the provider at least two million dollars for services provided to patients referred in exchange for kickbacks. Because the provider obtained patient referrals by paying kickbacks, the provider should have not received any Medicare reimbursement. The discharge planners/case managers who received kickbacks from the provider also pled guilty and will be sentenced soon.

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), the primary enforcer of fraud and abuse prohibitions, says that discharge planners/case managers and social workers cannot accept the following from providers who want referrals:

·    Cash

·    Cash equivalents, such as gift cards or gift certificates

·    Non-cash items of more than nominal value

·    Free discharge planning services that case managers/discharge planners and social workers are obligated to provide

Discharge planners/case managers and social workers provide extremely important services that are valued by many patients and their families, but their credibility and trustworthiness is destroyed when they make referrals based on kickbacks received.

A word to managers and all the way up the chain of command to CEOs: whether or not you know when case managers/discharge planners accept kickbacks, the OIG may also hold you responsible. You may be responsible if you knew or should have known. The OIG has made it clear that your job is to monitor and to be vigilant. A good starting point is to put in place a policy and procedure requiring discharge planners/case managers to report in writing anything received from post-acute providers. Even better, how about a policy and procedure that prohibits all gifts?

Now a word to post-acute marketers: do not give kickbacks to discharge planners/case managers and social workers. It is simply untrue that you must give kickbacks in order to get referrals. The proverbial bottom line is: Do you like the color orange? Is an orange prison uniform your preferred fashion statement? Please stop now!

SDoH: How Safer Communities Act Can Provide Additional Funding

This article first appeared on RACmonitor.com on July 27, 2022.

---

From my June 13 Monitor Mondays segment on the impact of gun violence on healthcare to the time I researched for this segment, there have been 67 deaths and 404 injuries. 

Since last report, our bloodiest day was July 4, with the Highland Park mass shooting resulting in eight dead and 29 injured. Across the country that day, 11 died and 70 were injured by guns. In our previous listener poll, the majority of our listeners confirmed that gun violence—although not a direct responsibility of healthcare—is similar to any public health approach and is a healthcare concern that cannot be ignored by our communities when we evaluate health disparities. 

Similar to how we track other social determinants such as poverty levels, our gun violence data now identifies the likelihood of gun violence by zip code. For example, in Delaware a gun death occurs every three days compared to Florida where it is every three hours. 

Last month, the Biden administration and Congress passed the first major gun safety legislation in almost 30 years.  I would like to recognize that this bill is partly about gun regulations and mostly about mental health support. 

1. The bill expands an existing law which prevents people convicted of domestic abuse from owning a gun.

2. Expands background checks on people between ages 18 to 21 seeking to buy a gun

3. Requires more gun sellers to register as Federally Licensed Firearm Dealers

4. Creates some statues on gun trafficking

Now the mental health and public safety portion:

1. Significant increase in funding for mental health programs and school security

2. $750 million is provided to help states implement and run crisis intervention programs

3. Diversion of the $10 billion initial funds in the American Rescue Plan, much of what I reported on previously has not been spent now to address public safety and violence prevention

4. The National Institute of Health has since redirected and released targeted grants to support four high violence areas in parts of Chicago, Detroit, and Virginia.

5. The Department of Housing and Urban Development is opening $3.4 billion for local communities to incorporate community violence intervention strategies.

Now most applicable to us is, the U.S. Department of Health and Human Services (HHS) announced how Medicaid will reimburse certain community violence intervention programs like hospital-based violence interventions also known as trauma-informed care to individuals that have experienced violence.  

Regarding state Medicaid reimbursement, Illinois and Connecticut are the only states that have fully incorporated hospital-based intervention reimbursement into their plans, however I will include my link in the article this week on how other health systems may be able to coordinate with state Medicaid plans to access this additional funding ranging from mental health, physician reimbursement, rehabilitative services, and home health prevention for high-risk populations.

Programming Note: Listen to live reports on the social determinants of health every Monday on Monitor Mondays, 10 Eastern.

References

https://www.gunviolencearchive.org/reports/mass-shooting

https://www.whitehouse.gov/briefing-room/statements-releases/2022/07/11/fact-sheet-the-biden-administrations-21-executive-actions-to-reduce-gun-violence/

https://www.medicaid.gov/state-resource-center/downloads/allstatecall-20210427.pdf

Telehealth at the Intersection of SDoH

This article appeared on RACmonitor.com on June 29, 2022.

---

We all remember the day the locks were removed for telehealth to come flooding through the doors and into everyone’s household as a mechanism for healthcare delivery. In the darkness of the COVID pandemic, patients could have covered access to their physician from the comforts of their own home.  Prescriptions were electronically transferred to the pharmacy or delivered via mail order right to your door. The companies and options for services seemed overwhelmingly easy and we probably all wondered how long is this going to last?

While Medicare has agreed to continue telehealth approved coverage through December 2023, individual states may have already started putting in restrictions for when the public health emergency (PHE) ends. It will be important for hospitals and health systems to stay up to date with their state regulations. Key changes that are occurring across the country in various states, include the possibility for patients needing opioid management through drugs such as buprenorphine will be returning to in-person only visits. Also, depending on your state, patients would only be able to access telehealth services from in-state licensed providers or states that acknowledge reciprocity agreements for physicians. That means that a patient seeking medical care may have to go back to only seeing physicians within state lines and could no longer have a virtual visit with a physician in another state, unless that physician holds a license in the same state.  

 In Hawaii, House Bill 1980, is proposing limitations on audio-only visits with recommendations that audio-only services be used when all other options have been exhausted. We will have to see how that is going to be operationalized. Last month, CVS announced that they will no longer be accepting prescriptions for controlled substances from telehealth companies Cerebral and Done Health. The clash originated after the companies were criticized with concerns for over-prescribing controlled medications, such as Adderall.

Finally, in the growing abortion debate, telehealth companies that provide services to women across state lines and deliver mail order medication could significantly be restrained with the new abortion laws and the reversal of Roe vs. Wade.

So, what does this mean for the patient, not all telehealth is going away and at least for Medicare many options are still here to stay. However, the free for all that we once enjoyed of full access to any provider across the country via virtual means is going to be a little bit harder to access.

Programming Note: Listen to live reports on the social determinants of health every Monday on Monitor Mondays, 10 Easter.

References:

‘Untreated’: Patients with opioid addiction could soon lose access to virtual care – POLITICO

Telehealth licensing requirements and interstate compacts | Telehealth.HHS.gov

Medicare and Maryland: Lessons Learned

This article appeared on RACmonitor.com on June 22, 2022

---

Maryland is different from every other state when it comes to healthcare initiatives. 

Putting aside that Maryland was the state where I grew up, I was intrigued by the recent announcement from the Centers for Medicare & Medicaid Services (CMS) for the new Total Cost of Care Model for Maryland’s Primary Care Program.

In Track 3, primary care provider (PCP) offices will be receiving a flat visit fee for select primary care services and a prospective population-based payment, adjusted up or down for performance-based outcomes. This program will run from 2023 to 2026 and will retire the Track 1 program, with a requirement for the full transition by 2024.  

Under this model, Maryland is on course to save Medicare $1 billion by the end of 2023, and continue to transform the model for primary care by covering care management services, reducing hospitalization rates, and improving the quality of care for Medicare beneficiaries.

So, how did Maryland become so special in the value-based movement? It originated from a 2008 pilot program on hospital-wide readmission reductions, intended to incentivize value over volume.

The Maryland Hospital Association (MHA) upped its game when it partnered with CMS in 2014 to launch the all-payor model, which established global budgets for certain Maryland hospitals to reduce Medicare hospital expenditures and improve the quality of care. The hospital payment program provides population-based payment amounts to cover all hospital services provided during the year, thus creating financial incentives for hospitals to reduce resource utilization to capture additional revenue.

In 2018, the Maryland Total Cost of Care (TCOC) Model was developed by the CMS Innovation Center to push care delivery standards across the care continuum. The TCOC Model is the first of its kind to hold the state fully at risk for the total cost of care for their Medicare beneficiaries.   

According to the MHA, the Maryland Model focuses on three pillars: equity, community, and value. So, how are they performing thus far? To date, Maryland has decreased its total cost of care spending growth rate by 3.8 percent, compared to the nation at large, and as of 2019, the cumulative impact of savings is up to $796 million. However, although inpatient visits have decreased, ED and observation stays have not. Likewise, of the inpatient hospitalizations, the patient severity (and thus payment per admission) has increased.

So, although CMS and MHA continue to experience success, I wanted to see what the frontline thinks – so I reached out to my trusty Maryland colleagues, Dr. Amit Wadhwa and Dr. Bernie Ravitz. I heard from them that like all things, the Maryland Model has its pros and cons, but they saw the benefits during the height of the COVID-19 pandemic, when their hospitals were trying to stabilize and manage patient volumes.

So, I ask: do you think the CMS payment system that Maryland has for the total cost of care could be replicated in other states?

To learn how others have responded to the Monitor Mondays listener survey, click here.

Programming Note: Listen to Tiffany Ferguson live reporting on the SDoH every Monday on Monitor Mondays at 10 Eastern.

MACPAC Addresses SDOH for Medicaid Recipients

This article appeared on RACmonitor on June 8, 2022

---

The MACPAC (different from the RACs, or Recovery Audit Contractors) stands for the Medicaid and CHIP (Children’s Health Insurance Program) Payment and Access Commission. This organization released an issue brief last month on “Financing Strategies to Address the Social Determinants of Health in Medicaid’.” 

The brief set out to address the extent to which Medicaid beneficiaries experience social risk factors that affect their health. It then focused on the primary mechanisms for how these factors could be addressed, either through state plan benefits, contracts with managed care plans, and/or state waivers or grants. 

So, here is what we learned about our Medicaid population: first, in 2020, the rate of food insecurity for low-income households was more than double the national average. In 2019, Black, Hispanic, and Indigenous American beneficiaries were more likely than their white counterparts to pay unaffordable rent, be unemployed, and lack high-speed Internet, and were more likely to obtain Supplemental Nutrition Assistance Program benefits.

When it comes to financial benefits that could be provided to Medicaid recipients, the options were all over the place. A key factor is the logistics of how each state manages its Medicaid program, who they consider eligible for services, and how they choose to delegate funding, either through a state-run plan or a managed care plan. Generically, the federal government has offered across-the-board services, such as options for case management and non-emergency medical transportation; however, there are still limitations in even these options. For instance, a mother needing medical transport may or may not be able to allow her child to ride along to the appointment, depending on her state, and thus may have to find childcare. Some states, such as Colorado, provide additional case management services for individuals transitioning from institutional settings back into the community; however, in other states, where managed care organizations (MCOs) run the Medicaid plans, case management services are strictly maintained through the payors. 

I am just reading the report, and I am already overwhelmed by the red tape and logistics of determining the possibility of benefits (or lack thereof). Being poor is a full-time job, and as reported by The Hastings Center, “being poor with chronic illness is two full-time jobs.” Poor people are often so preoccupied with the challenges of daily living that they have less “bandwidth” to care for or maintain their health.  Anyone who has tried to arrange a ride through a transport company for their Medicaid patients understands the logistical difficulties with multiple switchboards, entities that although contracted do not want to accept Medicaid patients because there is no tip, and often learning that there is a four-hour window for when the ride will actually arrive. 

So, I ask, do you think Medicaid should help cover social determinants of health (SDOH) services for their recipients such as housing and food support?

To learn how others have responded to the Monitor Mondays listener survey, click here.

Programming Note: Listen to Tiffany Ferguson live reporting on the SDOH every Monday on Monitor Mondays at 10 Eastern.

Staffing Acute Care Facilities in 2022

We are all tired of talking about that virus that popped up in 2019. So tired of it that I am not going to call it by name in this article! Unfortunately, over the past several years, hospitals have worked through unprecedented staffing challenges and assisted in managing caregivers through the emotional toll that has affected us all. But now, in 2022, as we seem to be on the other side of things, how are we going to address the staffing shortages related to burnout and a change of perception in the workplace? What will be required to create new tactics by senior leadership to engage all team members and to attract talent into the hospital setting?

According to an Altarum analysis of healthcare employment, hospital employment is down 31,000 jobs in the first three quarters of 2021 (SHSS-Labor_Brief, 2021). Overall, during this time period, total health care employment is down by 524,000 jobs. This includes jobs across the spectrum of the industry such areas as dietary, patient registration, environmental services, and continues up through the need for nurses and physicians to provide patient care. Burnout and heavy workloads have been the driving force of this change in statistics. Another key piece for consideration is the staffing influence that the Millennials affect. They are entering the workforce and currently make up the largest working population in the U.S. By 2025, they will represent 75% of the global workforce.

So how do we attract staff to come to our facilities? Without people and the talent that they bring, our organizations cannot sustain. First steps are to create a strong orientation program that develops inclusion with a sense of belonging to the organization reflected through teamwork and collaboration. Next, include and encourage the Millennials and newest members of your team to be included in your development processes. This group has grown up with electronic devices in their hands and bring fresh ideas! Do not let old ways lead without room for new ideas and input, especially when it comes to IT support and implementation.

Engaging staff and continuing retention will be key for this change in the workforce and the outlook on work life balance for all generations. In the acute setting, considering flexibility in roles and assignments can be difficult but must be top of mind as so many individuals are considering remote positions. Review thoughtless mandates that violate autonomy when possible. When interviewing new prospects, be clear on what is most important and discuss and highlight what you can offer to them that sets your organization apart. What makes your organization a compelling choice and are your offerings competitive in the current market?

A revolving door of talent at any level creates ripples that affects the progress of hospital systems and the retainment of experienced staff at any singular employer. These key elements make succession planning difficult so how do we address this?  Appeal to what matters to people and create a value proposition for what your organization can offer to recruits. For current staff, connect what you do daily that creates an exceptional atmosphere and demonstrates to your team that you appreciate them and support them in both their long-term needs and goals. Contribute to their lifelong learning and offer opportunities for professional development and promotion. A leader who is engaged and involved inspires others to develop into the next generation of effective and inspiring leaders.  Create staff who feel connected and empowered to be their best and are dramatically less likely to leave their current position but strive to be that next generation leader!

References

SHSS-Labor_Brief. (2021, September). Retrieved from Altarum: Health Sector Economic Indictaors: altarum.org/sites/default/files/uploaded-publication-files/SHSS-Labor_Brief_Oct_2021.pdf

Mental Health Awareness & Honoring our Healthcare Workers

This article was published on RACmonitor.com on May 18, 2022

---

I was fulfilling my case management responsibilities in the hospital last week and thus like many others in healthcare was eating a lot of food from all the celebrations. Last week we honored nurse’s week and hospital week. The American Hospital Association has chosen this year to “focus on the caregivers that have taken on unimaginable challenges and have risen to the occasion by working the frontlines during the pandemic and are continuing to stay as we try to recover and heal.” This message is so fitting as May is also Mental Health Awareness month. 

In between the celebrations, I listened to examples of staff adjusting to our current state of healthcare.  An SW came into the office needing to process the events of needing to remove a patient’s belongings from his body bag in the morgue to help locate and contact his loved ones. Not a typical occurrence these days however she was overwhelmed by the last two years where she never thought she would be discharged planning the dead. A UR nurse was upset in our staff meeting because we were discussing the plans to return one of the UR assignments to the ED. Although the UR workload has returned to normal, she was overwhelmed having lost another employee on the team to work from home employment and was nervous about going into the ED environment, given the last 2 years. 

A recent article was published in the Professional Case Management Journal by our very own Ellen Fink-Samnick discusses the collective occupational trauma and its impact on health care quality. The statistics are saddening in that 50 percent of nurses cited severe emotional toll related to staffing levels and workload intensity. Additionally, 75 percent of the healthcare workforce reported mental and physical exhaustion from the pandemic and almost half of the physicians are reporting burnout.

Recently, 5,000 nurses went on strike at Stanford’s hospitals requesting better pay, more staffing, and support for their mental health.  Additionally, one-day nursing strikes have popped up across the country with signs saying ‘burned out and tired’. And I don’t think we have seen the last of this.

So, to the staff that came into our office, I could not fix their experience, but I could listen and allow space for their trauma, and grief, and give compassion and honor to their requests and needed time to heal.  Although the week of food and treats is commendable, the bigger issue of ensuring safe work conditions for our healthcare workers is now a national crisis. 

To all the health care workers on the frontlines and behind the scenes keeping everything running.  I celebrate and honor you for your commitment to service. Cookies, snacks, and free lunch are not enough to say thank you and you deserve so much more!

To view this week’s survey about mental health awareness, click here.

References:

Collective Occupational Trauma, Health Care Quality, and Tra… : Professional Case Management (lww.com)

IPPS and Maternal Health

This article was published on RACmonitor.com on May 4, 2022.

---

A large focus on the 2023 Inpatient Prospective Payment System Proposed  Rule (IPPS) includes maternal health.  This is timely not only because of the concerning data that has been released but also because Sunday is Mother’s Day.  

In the IPPS proposed rule, the Centers for Medicare & Medicaid Services (CMS) is requesting the establishment of a maternity care quality hospital designation to be publicly reported on a CMS website. The website has not been specified yet by CMS.

Under the proposal, CMS would initially give this designation to hospitals that participated in the Maternal Morbidity Structural Measure finalized in the FY 2022 IPPS ruling for the reporting under the Hospital Inpatient Quality Reporting (IQR) Program.

CMS is proposing to add a scoring methodology related to measures around cesarean births and severe obstetric complications.  CMS is additionally looking for public comment on ways to improve health equity and reduce existing disparities around maternal care and subsequent health outcomes.  So, why is this so important, last month I reported on the growing disparities in maternal care.  In 2020 the U.S. saw a rise in maternal deaths to a case rate of 23.5 per 100,000 births.  This was not a new increase, but a continued growth in maternal deaths in our country since 2018.

The U.S. has the highest rate of maternal deaths among high-income countries, and black women are nearly three times more likely to die from pregnancy related complications than white women. To give perspective, the second worst country is France at 8.7 per 100,000 deaths, that is a delta of 14.8 deaths per 100,000 births.

The proposal by CMS is really a very limited easy first step, however it appears the causes of maternal mortality are not yet known.  The White House is continuing to focus public attention and additional funding for research and services to improve maternal health outcomes. 

Commonwealth recently highlighted a lack of health coverage and lack of access to maternal care as a possible causational factor.  CMS is also investigating and putting emphasis on improving standards of care around hypertension and complications such as hemorrhaging, preeclampsia and sepsis to impact these concerning statistics. 

Considering our approaching Mother’s Day, I would hope that we continue momentum to value the care delivery process needed for our expectant mothers.

Palliative Care a Win for Both Patient and Hospital System

This article is from April 2022

---

Palliative care is a phrase may strike fear and confusion in patients and their family members as it is commonly associated with hospice. To the average lay person, hospice equates to treatment support for dying.  But the definition of palliative care is specialized support and treatment for people living with a serious illness. Care focuses on providing relief from the symptoms and stress of the illness to improve the quality of life for both the patient and family (getpalliativecare.com, 2022).

My 74-year-old mother was diagnosed with Carcinoid cancer nine years ago with an expected survival timeline from diagnosis of five years. She has received treatments during the nine years that have affected her overall health including her cardiac and respiratory function. She has received her cancer treatment from the same oncologist, who my mother and father trust and respect, and have trusted his guiding and recommended treatment plan throughout her diagnosis. Due to a recent and obvious decline in her health, the oncologist recommended palliative care services to my mother with an empathetic and clear explanation of what the services can provide. Her immediate reaction was to decline the program and she and my father took offense to this offering. As her daughter, and a nurse who has spent the last 15 years in case management, I had a conversation with her to explain the benefits but to no avail. It felt like the days of trying to teach my kids elementary school math while they told me I was wrong!

So, the topic to consider is, how do we involve palliative care and how can it improve the patients’ transition of care? During my years in case management, I have seen advances in the acceptance and expansion of palliative care in the acute hospital setting. In proactive and forward-thinking organizations, the palliative care team attends critical care and medical multidisciplinary rounds. During rounds, this team can assist in identifying patients that are appropriate for referral and participation in the program. The importance of these conversations during the acute hospitalization cannot be undervalued. Connecting with the patient and family prior to discharge builds a relationship that increases compliance with the program once the patient is discharged home. To some degree, you have a captive audience that is looking for answers and relief while they are suffering from their acute symptoms. Once they are home and back to their baseline, it can be more difficult to engage them in a conversation and plan of care development. Patients that qualify for palliative care often have chronic issues that they have been managing and coping with for years and at times, for decades.

Patients with chronic conditions are also the same patients that often-become frequent ED visits and/ or frequent readmissions to a hospital bed. Whether they remain in the ED or are admitted, these patients use hospital resources to meet social and medical needs that could have likely been managed by an outpatient palliative care program. And many times, the support these patients’ need are often related to social isolation. The lack of social connections can also lead to associated risks such as depression, anxiety, and suicide. Recently, I was involved in a palliative care meeting related to a frequent readmit patient with chronic conditions who also verbalized that he preferred being admitted to the hospital because he is lonely at home. Now you would first assume that he would always be discharged from the ED without admission, but this patient was a chronic drinker who also had lab values and chronic conditions that fell within a range that clinically qualified him for an admission. And per admission criteria, the ED physicians were not comfortable with discharging the patient to home from the ED. Once admitted, the patient manipulated and found every reason possible to avoid discharge. Because the hospitalist covering on each admission varied, the patient got away with this behavior for several months before a care conference was scheduled.

After several meetings with case management and palliative care, the patient did agree to outpatient services. A palliative care outpatient program physician and nurse practitioner connected with the patient in the acute setting and discussed goals of care and home visits that initially occurred every few days at discharge.  Over the next several months, the number of ED visits and inpatient admission decreased for this patient.

This story was a success for both the patient and the hospital system that he was frequently readmitting to. Important to remember when developing a plan for a patient is to consider:

• What are the patient’s goals of care?

• What relief of chronic conditions and pain can be relieved to improve the patient’s quality of life?

• What is their current support in their home and community and what are gaps that can be filled?

• What emotional, spiritual, and practical needs does the patient need to be met?

In a quest for appropriate use of hospital level of care and outpatient treatment of patient’s chronic conditions, our health systems needs to consider not only the ailment affecting the patient but also the person being affected, what it means to them, and resources that can be used to improve their quality of life.

IPPS and the Social Determinants of Health

Article published April 27, 2022 on RACMonitor.com

---

There has been so much going on in the world of the social determinants of health (SDoH) over the last two weeks. Quoted from our Centers for Medicare & Medicaid Services (CMS) Administrator, who is rocking and rolling with press releases, Chiquita Brooks-LaSure explained in one that “Advancing health equity is the core work of (CMS). We can’t achieve our health system goals until everyone can attain the highest level of health.” 

I am sure I will be talking about her more as we cover the additional releases in the coming weeks. However, for the purposes of this article we are going to focus on the Inpatient Prospective Payment System (IPPS) release and open period for discussion related to the SDoH.

CMS is exploring how and if modifications need to be made to SDoH codes Z55-Z65, and how they may be able to improve their ability to recognize severity of illness, complexity of service, and/or utilization of resources under the MS-DRG system.

Specifically, CMS is looking at its connection to complication and comorbidity (CC)/major CC (CC/MCC) capture and the impact on hospital resource utilization. CMS is evaluating how improvements in documentation can lead to more accurate reporting for diagnosis codes describing the social and economic circumstances of our patients, in an effort to support the advancement of health equity – as well as improvements in data collection, nationally, regionally, and within hospitals and health systems, as an easy means to obtain relevant SDoH data on patient populations.

Recommendations are being made to capitalize on the Z codes, to look at internal health disparities, as well as health equity issues across the care continuum, impacting discharge planning and post-acute transfers.   

Consider the efforts that have been in place with the expansion of the Z codes in October 2021 and the clarification of clinician documentation to include details in the electronic medical record (EMR) from healthcare professionals. I would hope that coders are pulling in the great initial assessments from case management, which highlight many of the SDoH details that impact patient progression and transitions of care from the hospital setting.

However, CMS and I am concerned, which is why I am sure this is the impetus for the comment-and-question period. Because in 2019, CMS reported that Z codes for SDoH were only found on 1.59 percent of inpatient claims. And I get it; they are not required, and it is likely an extra step to find this information in the medical record.

Add to that the notion that many coders are overwhelmed by demands of quick turnaround for production, so claims can get out the door, with an ethical focus just on getting the diagnoses accurate. The ask for something else that is not required, and often not documented in the physician notes, which currently does not provide extra reimbursement for the health system, often falls to the bottom of the list of mounting priorities. I understand the apathy, but something needs to change to encourage greater utilization of the codes and therefore, CMS is requesting suggestions. Time to offer your advice and expertise.

So today I ask, are the SDoH Z codes being coded at your health system, to the best of your knowledge?

SNF and the Social Determinants of Health

Article published April 20, 2022 on RACmonitor.com

---

Last week, the Centers for Medicare & Medicaid Services (CMS) followed up on President Biden’s request to address the quality and delivery of care in skilled nursing facilities (SNFs). CMS issued a proposed rule that would update Medicare payment policies and rates for the 2023 fiscal year, and also introduced proposals for new data requirements for the SNF Quality Reporting program (QRP) and the SNF Value Based Program.

Essentially, the proposed rule is a bigger ask for skilled facilities, with less money available to do it. 

To assure budget neutrality, CMS is proposing to decrease SNF payments by 4.6 percent, which equates to about $1.7 billion. The adjustment is coming as a recalibration of the case-mix classification model also known as the Patient-Driven Payment Model (PDPM), which went into effect in late 2019. CMS had hoped that payments in the new model would lead to a decrease in charges and spending for skilled facilities, or at least neutrality from the old Resource Utilization Group (RUG) system; however, the change created an opposite effect, with an unintended increase in 5 percent of payments during 2020. The intended goal of this transition is to ensure that skilled nursing facilities are aligned with a patient-focused model, rather than a model based on numbers of services, such as amount of time completing physical therapy. The difficulty with this proposal is the historical reality of this time of calculation was during COVID, and forgive my frankness, but “no duh,” we used more SNFs during COVID, and they absolutely took care of sicker patients.

OK – now for the other items in the proposed rule include the following:

1. Proposed changes for the PDPM ICD-10 code mapping categories for physical therapy (PT), occupational therapy (OT), speech, and non-therapy ancillary services;

2. A request to add specific coding for patients who are in SNF infection isolation, with specific classifications for criteria to meet;

3. A request for input on the effects of direct care staffing, which include nursing, nursing assistants or aids, and other professionals, with specific intent to determine a minimum required staffing level. They are also looking at a potential SNF value-based purchasing measure to look at facility staffing turnover;

4. CMS is looking to add influenza vaccination coverage rates among facility healthcare personnel as a new measure to the SNF Quality Reporting Program, which begins in FY 2025; and

5. CMS is requesting to no longer delay the updated Minimum Data Set requirements, which include the transfer and standardization of data elements for race, ethnicity, preferred language, health literacy, and social isolation levels. This ties to their intent to increase reporting on health disparities, and to determine how to target future programs to address these concerns across the country.

So, what is the impact your organization could experience as a result of the Skilled Nursing Facility Prospective Payment System proposed rule?

To see the results from listeners during this week’s Monitor Mondays click here.

What to Do With the Complex Patients

Article published April 15, 2022 on RACmonitor.com

---

As we know, with the growth of outpatient surgical centers, advances in medical technology, and the shift of payers’ understanding in what they will consider to be an inpatient episode of care have all impacted the hospital patient composition.

Hospitalizations are seemingly more complex, requiring more attention from the multidisciplinary team. Prior to COVID, the focus on long length-of-stay patients had been a known, standardized process; however, hospitals and thus case management programs, including our beloved physician advisors, are feeling new pressure in the “Why are they still here?” discussion. During our great staffing exodus, the beds may be available to the patients rolling through the emergency room and out of the surgical suites; however, there is limited staffing across the systems to care for them in all areas. Fewer nurses, physical therapy is overwhelmed by consults, and environmental services (EVS) folks have been leaving just as fast as nursing for better wages and less stressful employment. The crunch becomes a reality when hospital administration sees the pain points at the front end, with patients holding for a bed, and they attribute it to the back end, when they learn that patients are delayed from exiting because of limited post-discharge options and case management staff, who cannot seem to keep up with the new demands. 

Although the focus looks at the front and the back, and yes, both are important to consider, it is just as important to consider the progression of care in the middle. On top of this stress of patients leaving, we examine the length of stay, and there is nothing more stressful to administration then to learn that a patient has been in the hospital for 100+ days and they are just finding out about it. These patients are like neon signs, adding to the already compounding issues of regular throughput and discharge concerns. However, they are different; they are complex, and an outlier to the typical movement of patients in and patients out. Thus, they require special consideration and special attention. 

When evaluating metrics and length of stay/cost of care considerations (the great debate), recognize that complex cases should be separated from the herd. They will skew the data, and really should be treated and managed as a concern separate from regular throughput and cost efficiency issues.

Everyday Progression of Care

The everyday process of interdisciplinary rounds (IDR) or huddle is not complex case review. IDR is when a multidisciplinary team – ideally including case management, utilization review, a physician advisor or attending (depending on hospital configuration), and nursing, at minimum – quickly discusses patients on the unit to anticipate and gauge care needs, as it pertains to the progression of care towards discharge. Depending on the size of the unit and the location, additional team members may be helpful to include, such as physical therapy on the orthopedic units. Also consider pharmacy and dietary for ICU patients and medically complex units such as oncology. The complex residents of the hospital do not need to be discussed in this daily huddle unless there is any pressing news to report. There is not enough time, and the goal is to communicate the progression for all the patients who have not moved into the hospital.

Complex Case Review

Now, weekly, there is a bigger group that meets to discuss your complex patients. This meeting is typically an hour, depending on the size of the hospital. The name of this meeting, although often debated, really does not matter; it should be clearly understood, and the necessary people should show up prepared. Consider who is leading this meeting – likely it will fall to case management and the physician advisor. Invite stakeholders who will be helpful when quickly reviewing these cases and can escalate concerns and consider the hospital pocketbook for helping to get these patients out. The list for selection criteria can be individualized to the hospital’s needs. If you pull a standardized set of patients, such as patients with stays of greater than 10 days, or days 50 percent or greater than the geometric mean length of stay (GMLOS), be flexible and remember that you may need to adjust criteria to ensure that your discussion is meaningful and really focuses on the patients who require this level of review. Case management should also be coming to the meeting and highlighting patients who are still in the ICU and appropriately medically complex, although important information is not needed for this type of meeting. Also, those in the hospital who are under “outpatient in bed” or social admissions should be discussed immediately to ensure that the group is alerted early. We do not want to wait until these patients hit a report to start the conversation. Additional thought should also be given to discuss long length-of-stay observation patients if this is a growing concern.

As mentioned, case management is at the table, along with the physician advisor, utilization review, patient financial services, a therapy representative, and relevant nursing leadership. Also, a representative from behavioral health, risk, and/or the palliative care team should be on hand, if the hospital has these programs, as it may be beneficial. During the meeting, each person must understand their role. Each case should be presented concisely as to why the patient is still in the hospital, then a discussion of barriers and needed support from the team should ensue. This should be a dialogue with questions, not a report or an interrogation of the case manager.

During this meeting, there may be patients who require more time than the group has allotted. A clear leader of this meeting will need to call out to the group and say, “Let’s table this patient” or “This patient requires a separate care conference, and who should be involved?” These are the patients who may require involvement with the hospital’s legal team, outside resources, community agencies, the patient’s insurance provider, and/or family, if involved. Any hospital that wants to move these patients out will need dedicated time to discuss just this one patient. This is a separate meeting that requires dedicated attention and ability to review all options on the table. The hospital may even have to build that table!

The Complex Case Manager (CCM)

The CCM is of growing popularity to provide attention and connection to this patient population. The CCM is essentially a “super” case manager who has experience already working as a case manager in hospitals and has the right skill set and willingness to tackle just this population. They can provide the time to dedicate to this difficult caseload, and are able to build up relationships with outside agencies to help with such issues as guardianship, abuse concerns, or moving of assets to obtain long-term care benefits. The addition of the CCM can be huge to the department, to help take these patients off the rest of the case management team. However, this position is often developed from an internal candidate with the right skill set. It is very hard to fill externally, because finding someone to cover this population without knowledge of the appropriate resources is a larger lift, especially in the current job market. Additionally, this position is a hard sell from a compensation aspect, with hospital HR departments that do not have a benchmarking tool for this job description. It really requires some finesse to find the right person and have backing from leadership. However, if it works out, it is worth putting in place.  

The complex patient population is a growing concern in case management programs across the country, and the nuances of what to do require creative options, dedicated time, and much energy from a multitude of stakeholders, in the hospital and in the community. To ensure that metrics are not skewed, this population should be removed from the standard data set and live in its own subcategory to highlight the variations between the regular progression of care and resource utilization performance. As the marketplace continues to shift, patient complexity is not going to go away, and thus, hospitals must be willing to adapt.

Gaining a Better Understanding of Advance Directives and Medical Necessity

Article published on RACmonitor.com April 6, 2022

---

Listening to one of our hospital partners describe rounds with complex cases, I heard of the following scenario: the patient was an 80-year-old male with advanced dementia, living in a nursing home with his wife, on day 20 in the hospital following an infection that impacted his previous shoulder replacement hardware, requiring removal and an antibiotic spacer. The patient also had a prior hip surgery and now had his infection impact this implant as well, requiring a replacement. The patient was found to have needed at least six weeks of IV antibiotics and another surgery for his shoulder, following completion of the antibiotics. Patient was still primarily bed-bound; his arm was in an immobilizer. The patient will need post-acute placement for IV antibiotics; however, due to his cognitive level, they were having difficulty placing him, and he became too acute to return to his nursing home. The patient was stable for discharge; however, they were unable to find an accepting facility, given his new level-of-care needs, thus rendering him unable to return to his home or his wife.

Understandably, there are a lot more details to this case that we will not cover in this article. However, the questions I asked the team at rounds was, “what was the patient’s goals of care?” and more specifically, “what were his advance directives?” Did this gentleman and/or his wife want to go down the road of significant treatment during this hospitalization? What does his future look like, knowing he will return to the hospital for more high-risk surgeries? The group replied, “we don’t know!” – and guess what, the chart did not know either. Granted, in the pressure involved with securing beds, the intention of the meeting was about “why has this patient not left yet?” However, as case managers, we are stewards to not only the progression of care, but also the utilization management of the organization. We must follow a standard of care to advocate on behalf of our patients.

Now, say the patient and/or wife said yes, we want to do everything. Then this example may look very different as it relates to the questions. Does the wife understand what “do everything for her husband” means? However, it was clear that this was a process error, with failure to stop and ask the necessary questions. When we consider value in care delivery, we must examine outcomes, which Dr. Hirsch confirms are incredibly hard to define. I will ask, “what is the likely outcome of this patient, and the intended impact to his already declining quality of life?”

Enacted in the 1990s, the Patient Self-Determination Act requires that hospitals and post-acute providers ask patients if they have an advance directive or a medical power of attorney, and/or check on their wishes prior to medical treatment. The intent of the law is to provide an opportunity for adults to express their desires about medical treatment in advance, and to educate the entire population on advance directives. Additionally, outpatient providers are incentivized financially through CPT® code 99497 to have advance directive conversations with their patients. However, a 2020 review of more than 60 high-quality recent studies on advance care planning found no impact on whether patients received the care they wanted, or how they rated the quality of their lives afterward.

In the quest for medical necessity and the pressure for achieving the appropriate level of care, I encourage our health systems to consider not only the ailment inflicting the patient, but the person being impacted by this care and what this means to them. Quoted from Dr. Daniela Lamas, in her New York Times essay “A Better Way to Face Death,” maybe we should be asking how our patients want to live, instead of how they want to die.

So today I ask, do you think the current process of obtaining advance directive information in your health system is having an impact on your hospital’s outcomes?

The Nursing Home Crisis Continues to Unfold

The article ran on RACmonitor.com on March 16, 2022

---

Coming off another week working inside the hospital walls in my case management world, I have another topic to discuss related to President Biden’s initiatives – specifically, Biden’s pledge to provide the country with better nursing homes. I am sure we all remember the horrific news of elderly residents dying of COVID during our first wave of the pandemic. By the end of 2021, approximately 200,000 long-term care residents and staff members had died of COVID, which equates to nearly a quarter of all our COVID deaths thus far.

The focus on quality ratings and educating our communities on post-acute services had started before COVID, when the Centers for Medicare & Medicaid Services (CMS) began publicly reporting skilled nursing facilities’ (SNFs’) star ratings in late 2018. Then, in late 2019 came CMS’s ruling and updates for discharge planning requirements, to include quality measures or ratings as part of the patient choice process for post-acute placement. Under value-based arrangements, many hospitals and health systems started working in collaboratives across the continuum to elevate performance and help improve quality of care for their patients going to post-acute care. 

However, the level of mortality with COVID is requiring more muscle. The Biden Administration intends to conduct research this year regarding the minimum required staffing levels at nursing homes, and potentially roll out mandates for all facilities shortly thereafter.

CMS plans to require the phasing out of shared rooms, particularly addressing facilities that have three or more residents in a room. They are also planning to beef up their penalties, reporting requirements, and scrutiny of nursing homes, especially those that are owned by private equity firms. In fact, private equity firms that own poorly performing nursing homes could face significant penalties, including permanent legal implications.

The need to improve care for our elderly is dire. However, as we continue to face significant staffing shortages across hospital systems, I am unsure where the staff is going to come from for nursing homes. Patients often are sitting in hospitals waiting for days for a bed to open at a post-acute facility, because of limited staffing. With limited bed availability has also come an ample supply of patient referrals for top-choice facilities. The unintended consequence is that facilities can pick the best patients from the pile, which means that those who are more complex or underinsured sit in the hospital as unlikely candidates for placement.

Case managers are working with patients and families to send referrals out to outlying communities and across regions to see who is willing to accept a patient to free up a hospital bed. Often, the choices available for placement are not five-star facilities. Imagine the physician and case manager telling a family that they are ready to discharge a loved one to a two-star or one-star facility, because those are the only ones available that take their insurance and have a bed available. 

This is a conversation we have all too often. And thus, the patient and family naturally request to stay in the hospital, where they feel they will be safer and more cared for until another facility becomes available, or they can figure out how to go home and access home care services.

So today I ask, how many of you think that SNFs will be prepared to increase staffing ratios for patient care by the end of the year? For the results of the survey, click here.

Findhelp Emerges as Leading Service to Help Providers Address the SDoH

Reported on RACMonitor, and Monitor Monday SDoH segment.

---

These are some of the latest updates regarding the social determinants of health (SDoH), and how our readers and listeners can get involved and seek out more information beyond data collection to produce valuable outcomes.

The SDoH are making their way into the technology world via providers finding ways to integrate them with electronic medical records (EMRs), creating a closed loop referral process for providers to connect patients with community resources. Today, we celebrate Findhelp.org for being ranked the No. 1 SDoH Health Network by KLAS Research.

I originally stumbled upon Findhelp, formally known as Aunt Bertha, when connecting with colleagues at a conference about eight years ago. I then researched the company, and it was not long before I was signing a contract to have them involved with my prior health system and connecting with the local nonprofits. 

CEO Erine Gray came up with the idea to help providers find services while he was acting as the primary caretake for his mother. Aunt Bertha was named after this idea of the wise aunt many of us have, who gives great advice and a helping hand. The intent was to have Aunt Bertha pick up where Uncle Sam leaves off, with a mission to connect people in need to the programs that serve them with dignity and ease.

Today, Findhelp is the largest, most widely used search engine to find free and reduced-cost programs by every ZIP code in the United States. They provide easy search options for customers looking for services offering food, housing, goods, transportation, healthcare, money, supportive care, education, work, and legal needs. For my fellow social workers, case managers, and community workers, they have an option for connecting directly with their local nonprofits.

Through a login and password, you can save and share your favorite lists for your patients and community members. You can refer patients to programs through the aforementioned closed loop process, and keep notes about the programs that people are finding the most helpful.

Findhelp has started to integrate with many EMRs, data analytics, and population health companies, such as Epic, Cerner, and Innovaccer. This data is being used to help support research and provide intelligence regarding services that communities are using – and lacking.

As of 2022, Findhelp is contracted with 275 healthcare and payer organizations, and they have also teamed up with local United Way chapters and 2-1-1 services to ensure that companies are working in the same direction when it comes to bridging access to services.

Understanding Healthcare's New Quintuple Aim

Discussed on Monitor Monday 2/7/2022 and published on RACMonitor.

---

The Quintuple Aim requires a dedicated practice to evaluate marginalized populations when considering how healthcare is delivered.

American healthcare has been marked by an evolution of marketplace trends that have impacted hospital leaderships in how they operate and achieve success. To adjust to the business of healthcare, hospitals have had to add unique positions to accommodate new considerations for how we define “value” to the patients and communities we serve. 

In the 80s and 90s, we saw the rise of managed care, which fueled the healthcare race for market share. Hospitals were gobbled up into major networks to create muscle with the payers and leverage better contracts and increased customer base. 

In the mid- to late 2000s, the Triple Aim became a major factor in the value equation for the Patient Protection and Affordable Care Act (PPACA) – and it is still the guide for the Institute for Health Improvement (IHI). The three prongs – improving patient experience, improving the health of our population, and reducing the cost of healthcare – are outlined as key methods to achieve value-based care. 

In 2014, we saw a new prong, making the Quadruple Aim. The fourth component suggested that without acknowledging physician and healthcare employee satisfaction, the Triple Aim was unachievable. This point still holds true today, as we see how burnout and occupational trauma of our healthcare workforce can easily lead to medical errors (and not the best customer experience). It is hard to give when you have nothing left in the tank. The significance of this aim was not that we need another component, but that the marketplace must consider its providers when determining the value of healthcare provided. 

Today, the new ask is for the Quintuple Aim, made particularly relevant over the last two years, as we must no longer ignore health disparities. The argument is once again that without the requirement for health equity, we will not achieve our value proposition of the right care, at the right place, at the right cost.

The Quintuple Aim requires a dedicated practice to evaluate marginalized populations in your community when considering how healthcare is delivered. This includes considerations for race, rural communities, age, individuals with disabilities, and poverty, to name a few.

The latest LAN report highlighted how great payers and health systems are at tracking data regarding social determinants of health (SDoH) and health disparities. But organizations and payers have not really determined clear guidelines or recommendations for how to act on the data that has been obtained. In my last reader poll, I asked about willingness to get involved to address health disparities in your community, and the most common answer was in line with the national trend: “I don’t know where to begin.” 

Some healthcare organizations and payers have started adding positions to focus attention on health disparities by adding vice presidents of health equity or managers of the SDoH. The difficulty with this question is that the answer is complex, specific to your community, and multifaceted.

Until we examine our communities for structural racism, variances in access to healthcare, housing, food, medications, education, and employment, we will struggle to achieve the real value of healthcare, which is to improve our patient’s health outcomes.

The IHI is still holding to the Triple Aim, and states that the additional concepts of employee burnout and health equity are important, but they are contributors to the success of the original North Star.

Evaluating outcomes of home health: a comparison of rural and urban settings

This article was originally published on RACMonitor and broadcasted for Monitor Monday on January 17, 2022

---

A five-year study looking at 7,900 home health agencies revealed interesting disparities.

The Journal of Rural Health published a recent article by the New York University (NYU) college of nursing that is catching some buzz regarding the health disparities between urban and rural settings.  The study looked at process and outcome measures over a five-year period, from 2014 to 2018. They compared the two geographic regions across approximately 7,900 home health agencies, looking at the timeliness of initiation of home health services, from the referral to the utilization of ED and hospitalizations. 

The results were telling, in the rural settings: home health agencies were better at starting new patients for services, either from the PCP office or the hospital discharge referral. Urban settings showed better outcomes and lower ED visits and hospitalizations for enrolled patients. However, the concern is that despite referrals for home health, both rural and urban locations showed an increase in utilization on ED and hospitalizations. So I ask: what is going on, and what can we do about this? Granted, this study ended before COVID began. However, the results highlight the continued concept that not one single service can always prevent a patient from returning to the ED or the hospital. 

So, here’s the concern: rural home health may be able to start working with patients in timely fashion, but they may be limited in their ability to navigate and coordinate resources to prevent the failsafe return for hospital services. Completing a home visit in a rural area means significant travel, with limited resources and staffing capabilities. There is less availability to providers and late-night services, and access to testing could take months and require traveling a long distance.

The ED and hospital, as we know, could offer immediate resolution. I am not even compounding the COVID factor of limited staff, delayed appointments, and overwhelmed EDs and hospitals.

Regardless of your geographic setting, urban or rural, the care of the patient is a public health concern that requires a community approach with multiple disciplines. Although there are best practices on how to reduce hospital utilization, the greatest outcomes arise when organizations collaborate openly – and creatively. 

The referral to home health is still a positive option, with continued support and care for the patient with eyes on their living environment, such as checking to ensure that there is food in the refrigerator, that old medications have been discarded, and that fall hazards have been removed. The referral also provides nursing and physical therapy services in the home, and support with infusions that could not otherwise be possible, along with many other things.

The Great Exodus is Hitting Case Management

During COVID we saw that hospitals were not only full of patients but there were also empty beds, because of limited staff to handle the capacity. Now, is not the time to revert to our pre-COVID ways.

---

A nurse at my local hospital posted on social media, asking if anyone would be willing to house her and her four children so she could be a traveler nurse. The replies came flooding from colleagues and friends, including those in case management, which highlighted the discrepancy in pay and support for nurses that continue to work at the hospital as employees’ verse those who leave for traveler jobs. The jokes flooded about pizza parties and candy rewards as support for employee engagement.

A staff pizza party is not enough!

Although the social post was tongue and cheek, the national evidence of short-staffed departments across the country is evident. Nurses, social workers, therapists, advanced practice providers, etc. are leaving in droves for a better opportunity that offers flexibility, ability to work from home, better benefits, and higher pay. However, for the staff that are unable to leave their current employer because of personal circumstances, disengagement is at new levels with burnout associated with the ongoing pandemic and subsequently working short staffed for less pay, while you work side-side with travelers making twice as much.

A common metric for hospital departments is to decrease contract labor, however this metric has only exacerbated and highlighted a growing organizational shift. Pre-COVID, a focus on contract labor was a metric for individual departments to evaluate budgeted cost and to encourage a focus on staff retention and engagement.

Similar problems are hitting the care management department as nurses and social workers have the open opportunity to work remote, join traveler engagements, or leave for higher wages and better benefits. The market is open season and the hospitals and companies that have figured out how to invest in new and retain existing employees have an advantage for those choosing to stay in healthcare. Such as Washington-based Providence Healthcare that announced in September an investment of $220 million to retain and obtain new healthcare employees. There offerings include, higher wages, sign on bonus, greater benefits and supports for per diem and part-time staff (Muoio, 2021). It used to be that you were competing against the hospital down the street, now you are also competing with top employers around the country who are willing to adapt with better options to support and bring in talent.

Once upon a time when a company needed to hire, they simply put an ad in the paper or online and things just happened. We did not really pay attention to the how or when or the why. Someone, someday got hired. And then came COVID. Hiring is no longer something that we just do. Now there must be a strategic thought process in place to attract the best talent and retain them. The quicker we understand this, the better and faster we will hire.

So, what can we do?

There are books and lectures on the importance of the first impression and how lasting that first impression truly is. And yet sadly, the first point of contact can be frustrating, abrupt and at times antagonistic. Even as we have facilities offering $20,000 sign up bonusses, relocation and sweetening benefit packages, we have delayed or no response to resumes, antiquated online applications and less than warm first contact. Let’s review the departments goals and break down the process and ways to improve the initial contact.

Often in facilities human resources are recruiting for everything from doctors to mail clerks, CNA's, bedside nurses, anesthesiologists, and RN/SW case managers. While, so many are fighting for so few, maybe it's time to consider a Recruiting Process Outsourcing (RPO) firm for some of the more specialized positions such as nurse case managers, CDI, and appeals & denials. While working so many jobs it may be difficult for human resources to have a strong network. An RPO specializing in niche positions may be a better option. By making the right investment up front for top talent you are ensuring a successful team, patient experience, and revenue cycle.

Invest in your staff! Take the time to listen to what they need to feel supported and invested in as regards to staff support and engagement. Review your responses from your annual employee engagement survey and break down the details with your team on areas that were low scoring. This may be a great time to consider staff lead initiatives to bring address those items that they feel they are missing such as education. Consider the investment in money towards conferences, organizations, virtual in-services, and seminars, they will appreciate their employer and patients will benefit.

Internally, the case management department can also alleviate the burden of working short staffed by taking this time to reimagine department functions. Break down the jobs and think about what can be absorbed and what could be replaced with a different level of employees for support. Not every job has to be completed by an RN or a social worker. Evaluate job duties to having everyone work to top of licensure and then filling in the other needs with supportive labor to help alleviate the burden of staff overtime and high caseloads.

Care management should consider the needs of the department and staff that are looking to move up in their career. What are the opportunities for lateral and vertical movement in the organization or department? When nurses start working at the bedside, there is a career path for them. That career path often leads to charge nurse, DON or CNO. Consider how a similar path can be created in the organization for nurses looking at the business side of healthcare in revenue cycle, UR, or CM, or even informatics and CDI[T1] .

Staffing shortages can lead to desperation but please do not resort to poor hiring practices. We all know the skillset we are looking for in a nurse case manager, med-surg, critical care or telemetry bedside experience and good computer skills. Historically when there is a shortage, we have seen nurses with limited to no bedside experience thrown on an oncology unit. Not only will this individual need additional training, but the current employees will most likely feel undervalued and burdened. Any choice in hiring will still require the initial investment of proper training to ensure they are set up to succeed.

During COVID we saw that hospitals were not only full of patients but there were also empty beds, because of limited staff to handle the capacity. Now, is not the time to revert to our pre-COVID ways. We should acknowledge those who stayed in the healthcare environment through multiple COVID waves, vaccine protests, mask mandates, and political unrest. We need to be as competitive in our retention benefits as we are in hiring. We show our employees that we always value them as they continue to show up every day, on time, to care for the sick. We should consider how we can support and encourage those who are entering the field of healthcare and provide additional on the job education and guidance for success. The quality of our healthcare system is dependent on staff continuing to show up prepared and supported to offer safe care to our communities and patients.

References

Muoio, D. Fierce Healthcare Providence Invests $220 million to bolster, retain workforce amid nationwide labor shortage. September 2021. https://www.fiercehealthcare.com/hospitals/providence-invests-220m-to-bolster-retain-workforce-amid-nationwide-labor-shortage