Why Is That Patient Still Here?
As case managers, we have all heard the question, “Why is that patient still here?”
This article appeared on the CMSA.org blog in August 2022. View the original article at https://cmsa.org/why-is-that-patient-still-here/#comment-2486
Rounding and Complex Patients
As case managers, we have all heard the question, “Why is that patient still here?” The question may have come from the attending physician or maybe from senior leadership, but the question is always directed to the case manager! While these complex cases can feel overwhelming, there are strategies to be used that increase the efficiency of discharging these time-consuming patients. The use of daily interdisciplinary rounds and establishing processes for further review of complex cases develops pathways for difficult cases towards a transition of care plan while expediting difficult discharge barriers.
Daily Rounds and Progression of Care
Daily interdisciplinary rounds should occur at the same time and location every day with attendance by the case manager, floor nurse or supervisor who has rounded on all patients on the unit, utilization review, physical therapy and physician advisor or attending, dependent on your model and availability. If you move the meeting time or location, you may lose attendees. Keep it consistent Monday through Friday so that they become part of the team's daily routine. Weekend rounds are not usually possible as we drop to a skeleton crew and put out fires all day! Additional attendees can include pharmacy, palliative and dietary care on specialty units such as the ICU. The focus of daily rounds is a progression of care for patients who are expected to discharge today or tomorrow. A few questions that need to be answered: What are the barriers? From a medical perspective, what needs to occur for the patients to discharge? What does the CM need to do today for the patients to be ready on their discharge date? These rounds need to move quickly through, likely 1-2 minutes per patient and typically occur on or near the nursing unit.
Complex Cases
Complex cases that are length of stay outliers occur related to medical and social situations and should be discussed during a weekly meeting. Locations of this meeting can be rounds to the units, case manager offices or in a meeting room. Discussions include patients who may be without a payer, are from another country, have guardianship or ethical issues, social or financial barriers that affect discharge and other outlier complexities that are individual to each patient. Regardless of which of these apply, these patients are typically very time-consuming and can become outlier patients who affect bed capacity and burnout of the hospital staff who care for them. They may also use an inappropriate amount of hospital resources during a time when healthcare is already incredibly strained and exhausted. With the current shortage of bedside nurses, the importance of this population of patients can affect daily operations in hospitals with a shortage of beds and staffing.
Weekly complex case review rounds can occur as physical rounding to the units or case manager offices or as a meeting in a designated space. Regardless of how your facility decides to process, this will meet the Medicare Conditions of Participation 482.30. The condition requires hospitals to conduct a review of duration of stays and professional services and for the meeting minutes related to these complex meetings. These meeting minutes need to be elevated to the Utilization Management Committee (UMC) for review. As stated above, the complex rounds meeting should occur once a week and include the case manager, social worker, case manager director and a Physician Advisor or Chief Medical Officer (CMO) in attendance. Additional stakeholders can include finance, palliative care, admissions and anyone who your organization feels adds value to the meeting. This is your meeting; make it work for your organization!
The length of stay of the patients discussed should also be determined by your team. Don’t decide on a 7-day length of stay review for this meeting and then discuss patients who are appropriate in the ICU at day 7. You may decide on a LOS of 7 days for med/ surg and 10 days for ICU. Find a starting place and adjust as needed to address those patients who are truly outliers. Case managers should also be encouraged to bring patients, even if it is the day they are admitted, that are obviously going to be a discharge challenge. Seasoned case managers will recognize these patients during the initial assessment. Talk about them early and start working on a plan as a team if you already know that they are likely to become an outlier.
Daily rounds create a forum to discuss those patients who should discharge today or tomorrow and ensure we have their needs addressed. Weekly complex discharge rounds give a place for the more complex patients to be discussed in more detail related to their individual needs. The use and combination of these two meetings will improve communication between the caregivers and stakeholders invested in the cost of care, progression of care and improved outcomes of the patients. Discharging these patients is a team effort and should involve senior leadership when required. Next time, they will not ask you why the patient is still admitted. Instead, they will be involved in the process and celebrate with you when that difficult patient has left! Complex patients may continue to increase and we, as case managers, will continue to work diligently to ensure they move safely and efficiently through the progression of care.
BIO: Marie Stinebuck MBA, MSN, ACM
Marie is the Chief Operating Officer of Phoenix Medical Management, Inc., the leading case management firm. Marie has practiced as a nurse for the past 25 years with 17 years in the field of case management. Marie has served in several roles in Senior Leadership roles in Case Management. Marie has authored numerous articles, is a weekly contributor on Finally Friday, and is a Board Member for the Arizona ACMA.
For more on how to move patients safely and efficiently through the progression of care, explore the online course "Improving Transitions of Care: What’s Working and What Have We Learned?" at https://www.pathlms.com/cmsa/courses/36380 (FREE to members!)
Making Meaning Out of Avoidable Days
Avoidable days can impact patient care and social determinants of health (SDoH).
This article appeared on RACmonitor.com on December 7, 2022
Avoidable days can impact patient care and social determinants of health (SDoH).
I always love working in the hospital with my fellow case managers, because it reminds me of the relevant issues and topics that colleagues are facing when they show up for work each day.
Today, let’s talk about avoidable days and discharge delays that occur with our patients, and how they can meaningfully impact patient care and social determinants of health (SDoH).
Avoidable days are tracked or logged delays in patients’ progression of care and/or discharge that have led to resource consumption without medical necessity. These days are often categorized by reason and attribution.
For instance, say a patient with a discharge order stayed overnight because they did not have a ride home. The reason is transportation, but the attribution may be nursing, because they did not phone a friend and figure it out. Or consider the patient who waited two days for a consultant to provide services and advise on the care the patient needed. The reason may be cardiology delay, and the attribution is Dr. X of blank cardiology group. Or consider the social admission wherein it is determined that the entire stay should be tracked as “avoidable.”
Whatever the reason, the goal for tracking these days is not to project them as a meaningless trend line, with a goal to artificially decrease them; this would result in people no longer reporting reasons!
The only reason this information is tracked is so the hospital and/or health system, likely through the case management department, can do something with it and impact change.
If you do not know your hospital’s internal costs, we can estimate, according to Kaiser Family Foundation 2020 national hospital data, that it is about $2,800, per patient day (see reference below). Then you can quantify the numbers to dollars and decide which services should be covered to support the patients’ care delivery and transition of care.
Going back to my original example, if you have one patient per week who stays overnight because “they didn’t have a ride home,” that is about $145,000 in annual waste, or 3 EVS workers. Turn the information into action by creating a story, as a hospital leader, for example by reaching out to a key foundation, collaborating with your community or post-acute providers, or painting a clear picture for executive leadership and the CFO on what reduction means. I also have justification for why the hospital should just easily cover the ride for the patient home – better yet, with a to-go meal and their prescriptions filled!
I could ask this question in a lot of ways, but I am going with this: do you know the top avoidable day reason at your hospital or health system?
Yes
No
We do not track avoidable days
Does not apply
The responses from Monitor Monday listeners may surprise you; they can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 a.m. EST.
Report: U.S. Charity Care Provided by Hospitals Leaving Much to be Desired
Healthcare provided to the most vulnerable populations often constitutes a tiny sliver of overall hospital budgets.
This article appeared on RACmonitor.com on November 16, 2022
Healthcare provided to the most vulnerable populations often constitutes a tiny sliver of overall hospital budgets.
Kaiser Family Foundation (Levinson, Hulver, & Neuman, 2022) recently released a report on national charity care levels for hospitals and health systems illustrating some dire financial news.
The report acknowledged that approximately 58 percent of U.S. households are currently earning below an annual income of $40,000, and estimated personal medical debt across the U.S. has reached approximately $195 billion.
However, charity care only represented 1.4 percent or less of total operating expenses at half of all hospitals in 2020, with significant variations across hospital designations. Additionally, it was found that 8 percent of all hospitals had 0.1 percent of operating expenses related to charity care.
It was also noted that there was no meaningful difference in charity care contributions between government, for-profit, and nonprofit hospitals. This was surprising, since as you know, nonprofit hospitals receive significant tax exemptions. The article did mention that despite nonprofit status, which makes up about 58 percent of all community hospitals in the U.S., many states have requirements that set expectations for all hospitals regardless of tax exemption to provide some level of charity care.
Before I throw some hospitals completely under the bus, I do want to acknowledge some factors that may contribute to the low numbers, which include potential discrepancies among hospitals in attributing charity care versus bad debt/write-offs.
However, many health systems were cited as not updating their charity care policies, and according to a 2021 study from Sage Publications on charity care, they found that in 2018, a total of 32 percent of hospitals continued to have stricter policies that expected patients to be at or below 200 percent of the federal poverty level. Understanding that many of these patients are likely already on Medicaid means very few such patients are actually receiving the benefits of full charity care. About 62 percent of hospitals in the study were found to offer discounted care for patients at or below 400 percent of the federal poverty level; however, it was reported that the definitions of “discounted care” were inconsistent across health systems (Bai, et.al, 2021).
In my continued digging, I was able to find a Journal of the American Medical Association (JAMA) study by Goodman, Flanagan, and Probst, who completed a cohort study of the top 170 nonprofit hospitals in the U.S. They found that 47 of the hospitals actually expanded charity coverage during the pandemic, while 12 hospitals further restricted their charity care, with the largest restriction being residency requirements for home locations within the community hospital region – and U.S. citizenship requirements. Some unusual exclusions were also found, such as denying charity care for birth control, or specialized outpatient services.
Do you think your hospital and/or health system is giving enough in charity care for your community? The responses from Monitor Mondays listeners may surprise you; they can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 a.m. EST.
Final Rule on Rural Healthcare Services
Release of the REH designations for 2023, indicates that CMS will only be covering outpatient, emergency, and observation care services.
This article appeared on RACmonitor.com on November 9, 2022
Release of the REH designations for 2023, indicates that CMS will only be covering outpatient, emergency, and observation care services.
Last Tuesday, the U.S. Department of Health and Human Services (HHS) released new updates to address health equity by increasing rural care access.
A press release made official the earlier proposed place of service titled Rural Emergency Hospitals (REHs). This designation will allow Critical Access Hospitals (CAHs) and small rural hospitals the opportunity to convert to REHs. When I reported on this back in August, there was concern that the REH designation would not cover inpatient services.
This has been confirmed with the release of REH designations for 2023, as they would only be covering outpatient, emergency, and observation care services. Similar to other place-of-service designations, the REH requirements establish a full range of health and safety standards, including requirements for services offered, staffing, and physical environment and emergency preparedness.
More specifically, REHs require:
A clinician on-call at all times and available on site within 30 or 60 minutes, depending on if the facility is located in a frontier area;
24/7 staffing to address emergency medical care with appropriate licensed professionals;
Maintaining and submitting ongoing data requirements for Quality Assurance and Performance Improvement Program (QAPI);
Annual per-patient average length of stay not to exceed 24 hours, and the time of calculation begins with registration check-in or triage and ends with the discharge time from the REH; and
An infection prevention and control and antibiotic stewardship program.
Okay, well, this is what it is, and thus rural hospitals or CAHs will have to decide if it is worth switching to the REH designation.
Additionally, Medicare is expanding the promotion of hospital outpatient departments to reimburse for remote behavioral health services provided to people at home. The Centers for Medicare & Medicaid Services (CMS) first implemented this policy through emergency rulemaking in response to the COVID-19 public health emergency (PHE). CMS has now officially made this ruling permanent to ensure continued access to behavioral health services via telemedicine in hospital outpatient departments. This rule requires that beneficiaries receive an in-person service within six months prior to the first-time hospital clinical staff provision of behavioral health services remotely, and there must be an in-person service within 12 months of the behavioral health service being furnished remotely.
CMS is clarifying if audio-only communication can be used, if video and audio capabilities are not available for remote services. They have made the intention clear that they do not want to discourage availability of behavioral health access because of technology limitations; however, I would just suggest that in all cases, ensure there is proper documentation to cover how the remote service was provided and why the patient could not do video, should this be an issue.
Today I ask a generic question: is your hospital or health system ready for all the 2023 CMS changes? The responses may surprise you; they can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 a.m. EST.
Why Has the Hospital Turned into Long-Term Care?
Often, the ability to move such a patient from the hospital into an appropriate setting is dependent on the social services in the local jurisdiction.
This article first appeared on RACmonitor.com on October 26, 2022
Theoretically, we know that patients needing custodial care are not supposed to be in the hospital without medical necessity, but in many cases, they show up in the emergency room and are admitted into the hospital because there is nowhere else for them to go.
The emergency-room physician believes that they can’t safely discharge the patient from the ED; however, they have no idea that once that patient, often a senior, goes upstairs to the hospital floor, the problem continues. Have we solved the problem, or have we just moved the problem from the ED to the hospital unit?
What happens next is often that the patient becomes a permanent resident of the hospital while the case management team attempts to mission-impossible a plan that will try to figure out supports, financials, long-term benefits, and all the logistics of getting this type of patient into permanent supportive housing. For every hospital our team visits, and in discussions with various healthcare leaders on this topic, the story is consistent, and unfortunately, not unique.
Often, the ability to move such a patient back into an appropriate setting is dependent on the social services in the local jurisdiction and the state governmental policies that exist for long-term benefits and permanent supportive housing. There are so many social complexities with these cases, many of which have nothing to do with the hospital setting. These patients can be in the hospital for months to years…yes, years…I have seen it!
According to the American Health Care Association and the National Association of Assisted Living, more than 325 nursing homes have closed since the pandemic, with another 400 expected to close by the end of 2022, based on current financial trends. And although I see plenty of assisted living homes popping up, many places that are closing are smaller facilities, meaning fewer than 100 beds, with at least 60 percent of their occupancy being Medicaid-dependent.
Based on the previous closures, most of these facilities had 4–5-star ratings on Medicare.gov. Additionally, it is reported that if the Public Health Emergency (PHE) ends, which would mean reductions to Medicare and Medicaid, an additional 32-38 percent of nursing homes would be at risk of closure. The total estimate is 417,000 seniors who would be at risk of losing their housing.
Alternative options are also limited, as low staffing levels continue to impact home care services in the home health and private duty sectors. The hospital is clearly not the best place to be, but where else are these patients supposed to go? I will continue to research this topic, and would love to hear from health systems and organizations that have come up with innovative approaches to solve this problem, to share on future broadcasts. Please feel free to email me at tferguson@phoenixmed.net.
Today I ask, are your health systems having difficulty with social admissions because of a lack of permanent supportive housing? The responses from the Monitor Mondays Listeners Survey may surprise you; they can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 a.m. EST.
How to Integrate a SDoH Coding and Quality Question
Quality reporting will be mandatory in 2024, and then under a payment determination in 2026.
This article appeared in RACmonitor.com on October 12, 2022
Last week I reported on the social determinants of health (SDoH) requirements for 2023, with many Monitor Mondays listeners being familiar with the Z code discussion. However, based on our listener survey, most respondents had not started working on the quality requirements under the social drivers of the health measure. So today, I would like to discuss how this can be incorporated into your workflow, and what will be needed from an electronic medical record (EMR) and documentation perspective.
To recap, the social drivers of health data submission is voluntary for 2023, which means it is a great time to test out workflows before 2024 – when reporting will be mandatory, and then fall under a payment determination in 2026.
Although there are many options for SDoH questions, and our EMR vendors may be creating their own mechanism, the Centers for Medicare & Medicaid Services (CMS) has specifically provided, cited, and recommended (although not required) the Health-Related Social Needs Screening Tool (HRSN).
Each hospital will need to have a mechanism for providing the HRSN questions that apply to the five domains – housing, transportation, food, utilities, and personal safety – to hospital inpatients who are 18 or older. You will need a mechanism that is discrete to pull data that says “yes” or “no” for questions provided to the patient. You would also need a discrete field to mark if the patient declined or was unable to answer. For those individuals who can complete the questions, hospitals will need to capture the positive screen metric by ensuring they have captured responses in all five domains.
Many of these questions live in the EMR and are asked in various ways, either by case managers, physicians, and/or nursing. However, are they in easy, discrete fields for quality reporting? And what is the consistency for asking these questions to our patient populations?
So, if we are considering who sees every inpatient upon admission, these questions fall into two areas: patient registration or the nursing admission assessment.
Once these questions are answered, case management and/or social workers can gladly be routed to follow up with the needed supportive services and elaborate with the patient on any of the responses. Like the ambulatory clinics, the medical assistant collects the information and then the chronic care manager does something with the information obtained.
I would recommend you maintain a consistent process for collection, capitalize on shared fields in the EMR that go across disciplines, and work with your coders so they can easily view this information to capture the Z codes.
For our listener survey, I would like to ask: Are you familiar with the Health-Related Social Needs Screening Tool (HRSN)?
Yes, very familiar
Somewhat
Not at all
The responses from the Monitor Mondays Listeners Survey may surprise you; they can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 a.m. EST.
New Hospital Reporting Requirements for SDoH
CMS has implemented two measures under its Hospital Inpatient Quality Reporting program.
This article appeared on RACmonitor on October 5, 2022
There is a lot of buzz in the Social Determinants of Health (SDoH) reporting and documenting world, and it is coming from all angles.
As reported recently in an article written by Erica Remer, MD, the final ruling for SDoH Z-codes is that they are continuing to evaluate their impact on MCC/CC capture and the Centers for Medicare & Medicaid Services (CMS) is continuing to recommend collection of these codes while they complete their analysis of impact, particularly the identification of Z59.0 homelessness (and its subcategories).
Additionally, CMS is finalizing the voluntary reporting for social drivers of health for 2023, which will be followed by mandatory reporting in 2024 with a payment determination to be in place by 2026.
CMS has implemented two measures under its Hospital Inpatient Quality Reporting program to collaborate with their 2023 ruling for Medicare Advantage plans to include Health Risk Assessments for their Special Needs Plans (SNP). The two measures that are being added are the Screening for Social Drivers of Health and the Screen Positive Rate for Social Drivers of Health. The measure is looking at the percentage of patients admitted to the hospital 18 or older that at the time of admission are screened for housing instability, transportation needs, utility difficulties, and interpersonal safety. This measure will look at two items: was the appropriate category of patients (inpatients 18 and older) screened in all five categories and which patients opted out of the screening or were unable to complete the screening during their stay.
To recap because this is a bit confusing. Hospitals in 2024 will have a mandated process to assess that they one offered an assessment on the five domains of social drivers of health and two that they complete the domains to collect and report this information. This will be submitted through Hospital Quality Reporting, but guess what coders, you can use it too!
CMS provides a tool that can be utilized called the Health-Related Social Needs Screening Tool (HRSN), (linked below). The tool is 26 questions, however for this reporting measure, only the first 10 questions are related to the five domains. Many of the other questions are already collected in the electronic medical record (EMR) during nursing admission documentation and/or case management initial assessments.
For our listener survey, I would like to ask: Is your hospital or healthcare system working on implementing SDoH questions into your documentation processes?
Yes
No
Unsure
Does Not Apply
The responses from the Monitor Monday listener survey may surprise you, and can be viewed here.
Programming Note: Listen to Tiffany Ferguson’s live reporting on the SDoH every Monday on Monitor Mondays at 10 Eastern.
References:
https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf
Looking to the Future: Striving for More Than Just Discharge Planning
I can remember when the movement of coordinating the progression of care became the hot topic for acute case management...
This article appeared on CMSA.org on September 26, 2022
I can remember when the movement of coordinating the progression of care became the hot topic for acute case management; suddenly, we moved from discharge planners to care coordinators with new titles and new models. It was around 2010 and I was working as a frontline social work case manager in my regional health system. The caseload then of 30 plus patients seemed overwhelming as I made the transition from a CM doing strictly discharge planning to care coordination. I was now expected to prepare for this thing called “interdisciplinary rounds” with the physicians and understand the patient progression of care. Our job descriptions were updated and training was completed, but a true transformation took years as we fine-tuned our art of case management in an evolving value-based healthcare landscape. I was expected to proactively screen my patients who were high risk and assess for resource utilization, ensure progression of care, and since 2012, make sure my patients had a safe transition to avoid readmission.
I wish I could say that this movement caught on like wildfire across hospital systems; however, now after we have been short-staffed and a bit shaken from the trauma of COVID, I have seen a loss of coordinating care and a return to just discharge planning. I am pained to see such regression; however, understand that many case management programs are still struggling with staffing. They are managing large caseloads or dealing with the continued turnover of travelers. Nurses and social workers are rotating as some trickling out of the system into remote work or retirement as the new green staff are coming in. This leaves leadership at a perpetual disadvantage unable to advance practice and instead stuck in managing schedules and assignments.
Settling into a new case management story:
So now in our new era, how do we ensure safe transitions while also supporting the progression of care and addressing the impact of our patients’ social determinants? How can we apply our critical thinking skills and ensure we appropriately support and advocate on behalf of our patients?
I think we start with the end in mind. How do we want to be envisioned to our patients and our stakeholders (physicians, nursing, etc.)? And then, we work backward. Remember, the discharge planner is simply acting on the care teams’ plans and suggestions continuingly in a responsive position. However, the care coordinator is identifying and contributing to the care team with suggestions and advice. Ideally, the case manager can spend time with their patients completing thorough assessments early in the hospitalization. They can provide helpful information and insight to support and advocate on behalf of the patient’s needs to ensure the right care, at the right place. They can effectively communicate these insights to the care team, the patient, and the post-acute and community partners. They are seen as the resource that time and time again prove their worth to physicians, nurses, and patients as an organizational staple “they could not live without.” However, to accomplish some of these things, I would say we need to let go of some of our old selves and consider a version for the future.
This means we cannot do it all!
There is a reason, when the hospital is full, that everyone is looking at the case managers to figure out why the patient has not left yet. It is because the assumption is that it is solely the case manager’s role to create a discharge plan and thus complete the tasks to get the patients out the door. Historically, it was; however, in the last 30 years, we have evolved and so should hospital staff’s perspectives. A patient’s progression of care is everyone’s responsibility and must be coordinated as such. Thus, case management must relinquish themselves from being involved in every patient and save their skill for those that are more complex. That means they must screen early in the admission and articulate clearly to the care team which patients can be discharged by nursing versus who require the complexity of the case manager or social work consultation. Additionally, they must be willing to relinquish the tasks that do not require a professional license and ensure there is support staff to handle those tasks. I always remind my nurses and social workers that we did not get advanced degrees to arrange rides or make follow-up appointments. Now, in a pinch, any member of the team should lend a hand; however, the system should not be designed for the case manager to be the tasker of discharge logistics. There are too few resources, and our time must be spent on more critical work.
Now is the time, and in honor of our 2022 Case Management Week theme, we should discuss at our staff meetings and within our departments: How do we elevate our case management programs and rebrand ourselves in our hospitals for the future, “Setting the standard for patient-centered care”?
Bio: Tiffany Ferguson, LMSW, CMAC, ACM, is CEO of Phoenix Medical Management, Inc., the case management company. Tiffany serves as an adjunct professor at Northern Arizona University, Dept. of Social Work and on the ACPA Observation Subcommittee. She serves as the SDoH specialist on the weekly news podcast, Monitor Monday. After practicing as a hospital social worker, she went on to serve as system Director of Case Management. Tiffany is a graduate of Northern Arizona University and received her MSW at UCLA.
To read more by Tiffany Ferguson go to: https://cmsatoday.com/?s=Tiffany+Ferguson
SDoH at the Intersection of Language and Healthcare
This story is in recognition of National Hispanic Heritage Month.
This article appeared on RACmonitor.com on September 20, 2022
The Centers for Medicare & Medicaid Services (CMS) Office of Minority Health has released healthcare materials that are targeted for our Hispanic patient population in honor and support for National Hispanic heritage month.
The recognition is key since Hispanic people have lower rates of health insurance coverage compared to their non-Hispanic counterparts and are disproportionately affected by chronic health conditions, such as diabetes, cancer, and health disease (Health Observance, 2022). To combat this disparity, the question is posed, “Are we providing our outreach and education in a culturally supportive means?”
I think this is a good reminder to assess and consider English as a second language is often a barrier to the care provided in the United States.
Remembering my days on the frontline as a medical social worker, there were numerous cases where I was working with Spanish speaking patients and families. I would try to complete my initial assessments and coordination of care services by relying on the hospital translator services which at the time was a blue phone that was never conveniently located in the hospital.
Eventually I moved to my cell phone putting translator services on speaker in the patient room to get us through the various care coordination and social work discussions. I remember I would often watch providers roll in the room and use family members as the official translator for the patient’s medical care and consents for procedures. Thankfully, hospital policies have progressed, so hopefully this is no longer common practice.
However, how often in the clinical setting are we asking the question to our bilingual patients, “Would you prefer a translator or interpreter in your native or primary language?” Here are a couple of examples of why this important. I often listen to our partner podcast, Talk Ten Tuesday, and each Tuesday I hear Laurie Johnson and Dr. Erica Remer list diagnoses and ICD-10 codes that I can’t even pronounce. Despite my advance degree, I have a health literacy deficit in understanding all the nuances of the physician and coding world.
Now, let’s take another example. What if I were in another country, where I did not speak the native language and needed medical care. How would I feel if that doctor speaking to me, as I felt sick or in pain, did not speak my language. I would be lost; I would be frustrated, and I would be completely helpless.
This month, the CMS Office of Minority Health is asking us to take the time to provide culturally relevant and linguistically appropriate materials to our patients. It is as simple as ensuring our patient education and consents are available in Spanish.
Now today’s question: How many of you, like me, have failed to consistently provide translation services or culturally relevant materials when providing services to our English as a second language patients?
Yes
No
Does not apply
The responses from the Monitor Monday 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.
Money Follows the Person
Understanding Medicaid’s Money Follows the Person (MFP) demonstration.
This article appeared on RACmonitor.com on August 31, 2022
This past week, the Centers for Medicare & Medicaid Services (CMS) announced that it would be expanding its Medicaid’s Money Follows the Person demonstration.
The program apparently has provided billions to help seniors and people with disabilities to safely transition from institutional care to homes and back to their communities. I had not heard of this program, and thus was surprised that it was being expanded.
The demonstration started as a pilot in 2006, then kicked off in a full demonstration effort which ran from 2008-2020 to support home and community-based services (HCBS) and reduce the use of institutional based care. During that time, more than 107,000 transitions were made out of institutional settings through a variety of different interventions. Many of the states have selected their own name for this funding program, which may be why there is a lack public recognition. States such as Pennsylvania, Kansas, and Missouri have coined the name for their MFP program “Finding Home” while other states have used the name, “My Place” or “Returning home.”
In the Consolidation Appropriations Act of 2021, an additional $5 million was awarded to states that were not previously participating in this program to access MFP funds which is run through the state’s government offices. This program has removed restrictions for Medicaid members to receive support for appropriate and necessary long-term services and supports people in the settings of their choice to secure stable housing and reduce risk of institutionalization, which includes unnecessary hospitalizations.
On March 31, 2022, the program was expanded to the current MFP grantees that they will receive increased reimbursement for these services with zero state cost share requirements. Yes, free federal money to support Medicaid members for community based and housing support services (HCBS).
Then last week, an additional $25 million, $5 million per awarded state, was awarded to expand programs in Illinois, Kansas, New Hampshire, American Samoa, and Puerto Rico. The funds will go towards establishing planning partnerships with community stakeholders, conducting assessments to better understand how HCBS supports residents, developing community transitions programs, enhancing HCBS quality initiatives, and recruiting additional staff and technology to support the infrastructure of these programs.
To date there are 41 states and territories participating in this program which is funded through 2025. Please check out the link and select the awarded grantees tab to see if your state is participating, who your contact is, and what requirements are needed for accessing these funds.
If you all are familiar with my recent webcast Long-Stay Hospitalizations: Managing the Complex Patient Populations, we discussed what to do with complex patients who have multiple ED utilization or long stay hospitalizations. Upon researching some of the state programs it appears that this is a program that hospital and outpatient community-based case management programs should be aware of and could access to support their complex patient population.
Although each state is unique, the program is routed typically through two areas the Office of Aging and Adult Services and the Office for Citizens with Developmental Disabilities. To meet the institutionalization criteria, the client and/or patient would need to have a length of stay of at least 60 days. However, in today’s current conditions and with true complex cases, this is not unheard of with social admissions in the hospital, NICU babies, or psychiatric patients.
Once eligibility is established, they would be able to access MFP funds to support transitions into less restrictive community-based housing depending on patient needs. These funds could also help support initial payments and coordination of services to transition the patient out of the institutional setting.
Monitor Monday listeners were asked if any of the listeners were familiar or if they had utilized their state-run Money Follows the Person program (i.e., Finding Home, My Place)?
Yes, I was already aware of this program
No, this program is new to me
The responses from the Monitor Monday 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:
SDoH at the Intersection of Healthcare Quality
Discussion around using Z codes to capture SDoH data
This article appeared on RACmonitor.com on August 24, 2022
EDITOR’S NOTE: This story is the result of JAMA Viewpoint article by Dr. Jorge Portuondo from the Center for Innovations in Quality, Effectiveness, and Safety out of the Veteran’s Administration Medical Center in Houston. Portuondo and colleagues released their opinion piece July 29, titled, “Using Administrative Codes to Measure Health Care Quality.”
The Portuondo article questions the value or impact of using diagnosis and procedural codes to measure health care quality. This makes me think of our previous debate about the underutilization of SDoH Z codes and the requirements to fall within the list of diagnosis and procedural codes.
Z codes have no quality or financial ties for reimbursement. In Portuondo’s discussion, he considers how directly tying diagnosis and procedural codes to value-based performance could create an opportunity to “game the system” so hospitals can optimize their coding practices to maximize reimbursement or performance on quality-based initiatives. I got a little defensive in my head reading this article. Thinking this is “not all hospitals” as we know that Medicare Advantage plans have also played their part with incentives to increase their patient RAF scores. In September 2021, the Office of the Inspector General (OIG) released their findings on a subset of Medicare Advantage plans having “suspicious” behavior related to their health risk assessments and diagnosis coding which significantly increased their risk-adjusted payments from the Centers for Medicare & Medicaid Services (CMS). Let’s consider the question ”If we continue to tie quality to reimbursement are we artificially depicting the value of care we are delivering?”
Obviously, this kind of article and the OIG reports in the last couple of years regarding coding has raised some opinions. We know patients receiving hospital care are likely more complex and likely do have comorbid conditions. However, we also understand that the publicly reported incentives from CMS for quality programs and reimbursement programs have changed coding practices due to the documentation capture requirements. Thankfully, the report and others, such as publications from the Commonwealth Fund have asked CMS to consider a separation of quality data registries from the coding and procedural billing codes. Hospitals are already required to report a significant amount of quality data to CMS across a spectrum of clinical specialties and disease registries. Could these mechanisms be used in a more meaningful way than the administrative data used for billing purposes?
So, let’s go back to the consideration of SDoH, I propose a hypothetical question to our audience should we continue the route of reporting Z codes as a coding process in line with our current coding procedures or should there be a separate means for capturing SDoH data?
Keep it the same (current Z codes)
Create a new mechanism for SDoH data
Unsure
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://oig.hhs.gov/oei/reports/OEI-03-17-00474.pdf
https://www.commonwealthfund.org/blog/2022/taking-stock-medicare-advantage-risk-adjustment
SDoH Recognized in the 2023 IPPS Final Rule
Some SDoH conditions are more likely than other to be impactful on healthcare consumption.
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
Are SNFs taking advantage of the PHE waiver?
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
Case managers/discharge planners continue to come under fire from fraud enforcers for violations of the federal anti-kickback statute.
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
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.
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.
The bill expands an existing law which prevents people convicted of domestic abuse from owning a gun.
Expands background checks on people between ages 18 to 21 seeking to buy a gun
Requires more gun sellers to register as Federally Licensed Firearm Dealers
Creates some statues on gun trafficking
Now the mental health and public safety portion:
Significant increase in funding for mental health programs and school security
$750 million is provided to help states implement and run crisis intervention programs
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
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.
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.medicaid.gov/state-resource-center/downloads/allstatecall-20210427.pdf
Telehealth at the Intersection of SDoH
Two years later, there are some changes to telehealth.
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
Maryland Total Cost of Care (TCOC) Model was developed by the CMS Innovation Center.
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
Benefits are largely dictated by how each state manages its Medicaid program.
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
How we can face recruitment and retention strategies in a post-COVID era.
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
Healthcare workers deserve more than parties and snacks.
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: