New SDoH Report Reveals Smoking, Drug, Alcohol Utilization History

This article appeared on RACmonitor.com on March 13, 2023.

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AHIMA makes policy recommendations for SDoH.

Last month the American Health Information Management Association (AHIMA), in partnership with the National Opinion Research Center (NORC) at the University of Chicago, released their final report on Social Determinants of Health (SDoH) Data. The survey was completed with a little more than 2,600 respondents to obtain a better understanding of how SDoH information is collected, coded, and used to inform the development of potential educational tools and resources that may be needed for health information professionals, as well as guidance for policy recommendations.

The report found that about 78 percent of respondents confirmed that their organization is collecting SDoH data primarily through electronic means, typically through the electronic medical record (EMR). Regarding the most prevalent SDoH domains, it appeared that collecting information for health and health behaviors was the highest priority among healthcare organizations. Examples of this information include health insurance coverage and health factors such as smoking history and drug or alcohol utilization. One can understand why this is easily collected data, as any service requires registration of health insurance/coverage benefits, and tobacco and substance use history is a standard in nursing and physician documentation.   

The second-most common factor was housing insecurity, followed by economic insecurity. However, after that it was really a grab bag of other SDoH factors in the rankings.

One of the policy recommendations from AHIMA was to create standardized, clinically valid, and actionable data elements for collection. I would strongly request that organizations follow the Centers for Medicare & Medicaid Services (CMS) social drivers of health, which at this time has prioritized housing, food, utility, transportation insecurity, and personal safety as the top issues.

However, I would absolutely agree with AHIMA that CMS’s quality metrics should be used in concert with the push for CMS’s SDoH z-code capture.     

Additionally, the report found that although the majority of respondents are consistently using ICD-10-CM for coding and collecting SDoH data, the tools that are utilized to screen and assess members are widely different. There was also a significant decline in the integration of this information into workflows after the data was collected. Obviously, the challenges inherent in this discrepancy were cited as being related to lack of training in how to find these details in the medical record (and then what to do with it once it has been collected). The limitations are likely tied to AHIMA’s second policy recommendation, which is the request for CMS to align financial incentives with these efforts around SDoH. 

I would absolutely agree with this request, as the amount of work needed to care for patients that struggle with such SDoH factors as housing insecurity significantly impacts the resources and amount of care medically needed for this population. Recognition of these efforts beyond internal data collection would absolutely go a long way. 

Programming note: Listen to live reports on SDoH with Tiffany Ferguson Tuesdays on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer, 10 Eastern.

Resource:

ahima_sdoh-data-report.pdf

Driving Home the Need for Discharge Transportation

This article appeared on RACmonitor.com on February 27, 2023

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Coordinating efforts in the electronic medical record (EMR) and across disciplines are keys to tackling the social determinants of health (SDoH) – and specifically, transportation.

Discharge delays related to transportation, whether avoidable or not, are a common occurrence for hospitalized patients. Some patients may have been transported great distances to a regional hospital, and now they need to return home, or they are being discharged to an alternative location and need transportation support to get to a post-acute location. Sometimes it is simply a delay because they do not have anyone to pick them up from the hospital, or they do not have a car that happens to be in the parking lot to drive themselves home after an emergency-room visit, procedure, or hospitalization. When appropriate, conversations with the patient and/or representative about potential discharge transportation needs should occur early in the hospitalization. In fact, a proactive approach would be to incorporate this as protocol. 

As we approach the social drivers of health requirements, hospital personnel are required to ask questions regarding transportation insecurity. Although I am not thrilled with the Health-Related Social Needs (HRSN) wording of questions related to transportation (as I think they are a bit cumbersome, and do not fit into natural conversation), one can easily still assess for patients’ potential transportation needs. Things I would want to know are if my patient is:

• Able to drive independently;

• Unable to drive or does not have access to transportation;

• Uses an insurance transportation benefit;

• Uses family or others for rides;

• Primarily uses public transportation; or

• Has no transportation resources.

Pending a response, one would want to provide necessary resources to the patient, as well as comments to the care team regarding what’s needed for the patient upon discharge to ensure that they are able to head home or to the post-acute facility timely and safely, without avoidable delays related to transportation insecurity. This may be an opportunity to develop outreach and provide resources to patients regarding community support services that allow them to be more successful in obtaining services related to their healthcare. At this time, consults for the post-acute resource center (PARC) could occur to ensure that the patient has a bus pass – or, one might give the transportation coordinator a heads-up that this patient will require a ride at discharge. 

From a coding perspective, the conditions impacting the patient’s hospitalization could be assessed if Z59.82, transportation insecurity, applies.

If this information was at the patient level in the medical record, the entire inpatient and outpatient care team could be aware of the transportation modality and provider the patient uses, with access to phone numbers should issues arise. 

From a data perspective, this information, listed in discrete fields, would allow the healthcare organization to assess how often patients are presenting with transportation needs and/or potential insecurity. Once quantified, there may be an opportunity for the hospital to partner with an outside vendor for transportation, or to purchase a shuttle to take patients home.

Does your hospital or healthcare organization struggle with patient transportation issues?

Programming note: Listen to Tiffany Ferguson’s live reporting on the social determinants of health (SDoH) Tuesdays on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.

Why Mixed Messages with the Social Determinants of Health

This article appeared on RACmonitor.com on February 20, 2023

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There appears to be an overlap of messages concerning the social drivers of health in the EMR.

The Centers for Medicare & Medicaid Services (CMS) continues to prioritize efforts with an emphasis on health equity, with greater data reporting and recommended capture of z-codes. I am seeing a lot of mixed messages, with overlap in the electronic medical record (EMR) regarding social determinants and social drivers of health (SDoH).

Social “determinants” is our documentation to support z-codes, while social “drivers” includes our documentation of quality measures for CMS’s value-based purchasing initiatives. I urge EMR vendors and health systems to develop a collaborative and non-siloed approach to capture this information.

How often do we look at information in the EMR for which details have been provided in a similar fashion and are documented in multiple locations? The goal should always be to identify the best location for where important personal information can be found and route everything back to the source of truth in the record. For instance, take a patient’s address.

As a case manager, I often update and find details of this information as we discuss home location with the patient; instead of putting this detail in my note, I ensure that it goes back to the source of truth in the record, the patient’s demographic section.   

When adding questions that meet the needs for quality reporting for the five domains of social drivers of transportation, utilities, personal safety, housing, and food insecurity, let’s look at what is already in the record and what can be adjusted to easily match existing workflow. Then let’s ensure that this information is available for all parties.

For instance, if the details of a patient’s living condition are impacting the care plan, that information should be accessible not only to the care team, but also the coding team, to ensure that they can appropriately capture these details. A collaborative session may be helpful, involving clinical documentation improvement (CDI), coding, nursing informatics, quality, and case management, to review the details in the record regarding the SDoH and where this information can be found.

Coding and quality can provide input on the specifications they may need that would help them clearly understand the impact of a particular social determinant on the hospitalization.

In most case management documentation templates, although not consistently used, are fields listing patient limitations or barriers to discharge. These include check boxes and comments for such factors as language barriers, limited social support, and financial stressors.

This information can help guide the coding team, and if any questions arise, via conversations with utilization review or the attending, it is perfectly okay to secure chat or query the case manager for clarification to ensure that we capture these details.

Are you reviewing case management documentation to capture z-codes related to the SDoH?

Programming note: Listen to Tiffany Ferguson’s live reporting on SDoH today on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.

Uncovering Sepsis as a Root Cause of Coding Mishaps

This article appeared on RACmonitor.com on February 13, 2023

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Some vendors will need education as to what criteria need applying.

A recent conversation developed among a client and a vendor that has a longstanding relationship with said client, with the topic at hand being documentation improvement efforts to increase case mix index (CMI) and diagnosis capture for clinical documentation integrity (CDI). 

In the utilization review (UR) world, I feel that it is vital to partner with CDI, because documentation is so important to both of us. Why list the diagnoses in the record if you fail to prove the medical necessity for treatment? CDI and UR should be in concert to ensure accuracy of the medical record to justify reimbursement and medical necessity for the care being provided.

During our discussion with the vendor, I raised some concerns we are seeing related to DRG downgrades, particularly associated with sepsis. This was news to the vendor, as they had only been focusing on Medicare and not contractual practices. I then asked the question of what their recommendations for sepsis were, and the answer was that “we strictly follow SIRS (systemic inflammatory response syndrome) criteria for diagnosis of sepsis.” 

At that moment, I must have channeled Dr. Erica Remer, because I then made the connection of why the Program for Evaluating Payment Patterns Electronic Report (PEPPER) showed outlier trends centered on coding, particularly for sepsis, as well as continued DRG issues that were masked under “lack of authorization,” “medical necessity,” and “clinical validation” denials or downgrades. 

When I asked if they had reviewed the client’s PEPPER, I was looked at as if I had two heads. At this point I realized that our journey to alignment was going to be a little bit longer than I had realized. But I decided to start with a generic example: a patient arrives in the hospital with all the evidence of an infection, meeting SIRS criteria. Sepsis is the working diagnosis while we evaluate what is going on; however, by day 2, it has been determined that the principal diagnosis was streptococcal pneumonia – yet the providers continued to copy and paste “likely sepsis.”

The chart is coded, billed, and then the denial comes, and the payer says, essentially, “we will pay you for streptococcal pneumonia, but we don’t think sepsis was clinically valid.” The finance people may think you have lost money, but the reality is that the patient belonged in the pneumonia DRG to begin with. 

Adjusting the principal diagnosis proactively will avoid having to expend the time and money to assess an erroneous denial on the back end. And pneumonia justified medical necessity just fine. 

Programming note: Listen to Tiffany Ferguson’s live reporting every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.

The End of the PHE is Near

This article appeared on ICD10monitor.com on February 6, 2023

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During the COVID-19 pandemic, our health system saw significant benefits under the federal public health emergency (PHE) waivers. Whether it was the expansion of telehealth or the removal of the three-day inpatient-stay skilled nursing facility (SNF) requirement, healthcare organizations were able to open care to their patients in ways they have not been able to in the past. Socially, we have learned that the PHE provided significant relief of healthcare expenditures for hospitals, particularly with the expansion of Medicaid. 

Research now provides evidence that the ripple effect of the PHE has also improved our country’s unemployment rate and decreased concerns over housing insecurity and eviction rates (Bailey, V. 2023). However, as we have already seen, many states are planning to roll back their Medicaid coverage when the PHE ends.

It is estimated that when the PHE ends, tentatively scheduled for May 11, between 5.3 million and 14.2 million Americans will lose coverage, and all Medicaid patients will be required to go through the redetermination process for eligibility. Starting in April, states are expected to meet the requirements for an unwinding process to phase out the continuous enrollment provisions from the PHE (Tolbert, J., & Ammula, M., January 11, 2023).  

This is going to have significant impact on our healthcare system, as patient registration and financial services will need to increase efforts to help patients complete their redeterminations, which all likely will result in a huge burden. At any level in the healthcare setting, we can expect changes in Medicaid coverage when patients may be unaware that they have lost their coverage or have a change in coverage. This also will result in delays for services, accessing care, medications, and post-acute transitions. Financially, healthcare will likely experience a rise in denials, bad debt, and uncompensated care. The Centers for Medicare & Medicaid Services (CMS) does have a z-code for those who have insufficient social insurance or are on welfare support: Z59.7.

So, what can health systems do to prepare?

Revenue cycle teams and patient financial services will need to have a good understanding of what will happen in their state when the PHE ends. CMS on Jan. 5 released requirements for each state to develop an operational plan for how they will be “unwinding” coverage from the PHE to their state Medicaid coverage determinations. I have included below a link put together by Georgetown University of each state’s plan and where they are in the process of preparing for the Medicaid rollback. 

Connecting with the local department of health and human services (HHS) offices will be vital to ensure that all access points for patient care provide information regarding the changes that will be coming in your local area. Frontline registration, scheduling, and financial assistance staff will want to be aware, and start helping patients obtain information regarding requirements for eligibility, which typically includes submitting updated income statements, tax returns, and proof of home address, such as copies of utility bills. If your hospital does not provide this, it may be a good time to start having conversations, so your healthcare system is not stuck with a significant number of uninsured patients.

Is your hospital or healthcare system prepared for the Medicaid changes when the PHE ends?   

Programming note: Listen to Tiffany Ferguson’s live reporting every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer, 10 a.m. EST.

References & Resources

Bailey, V. (January 18, 2023) Medicaid Expansion Helped Reduce Eviction Rates, Housing Insecurity. Public Payer News, Health Payer Intelligence.  Retrieved from Medicaid Expansion Helped Reduce Eviction Rates, Housing Insecurity (healthpayerintelligence.com)

Tolbert, J. & Ammula, M., (January 11, 2023) 10 Things to Know about the Unwinding of the Medicaid Continuous Enrollment Provision. Retrieved from https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/

50- State Unwinding Tracker: https://ccf.georgetown.edu/2022/09/06/state-unwinding-tracker/

CMSA Revises Standards of Practice Again

This article was published on January 12, 2023

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The Case Management Society of America (CMSA) issued revised Standards of Practice for Case Management in 2022. The Standards were first published in 1995 and revised in 2002, 2010, and 2016. The general purpose of the Standards is to identify important knowledge and skills for case managers, regardless of practice setting. CMSA decided to revise the Standards again in 2022 in order to emphasize the professional nature of the practice and role of case managers as an integral and necessary component of the health care delivery system.

According to the most recent revised Standards, the definition of case management is as follows:

"Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes."

The Standards go on to acknowledge that explaining case management to clients and the public can sometimes be challenging, so the revised Standards include a definition that can be used for clients and the public as follows:

"Case managers are healthcare professionals who serve as patient advocates to support, guide and coordinate care for patients, families, and caregivers as they navigate their health and wellness journeys."

Revised Standards reaffirm that professional case management practice spans all health care settings across the continuum of health and human services. Occupational therapists, pharmacists, physical therapists, and speech therapists were added to registered nurses, physicians, and social workers as professional disciplines of designated case managers.

The revised Standards also include substantial revisions to the section on Professional Case Management Roles and Responsibilities with a new emphasis on advocacy as a central role and responsibility of case managers as follows:

"The role of a Professional Case Manager concerning the patient is that of advocacy. Advocacy is used to coordinate the influential factors that affect the patient or a group of patients' ability to achieve their optimum state of health. The contributing factors to well-being include Financial, Ethics and Legal, Social Support, and Providers of care."

According to the revised Standards, in order to effectively advocate for patients Professional Case Managers are responsible for being patient-centered and are held accountable to maintain the education and skills needed to deliver quality care. Professional Case managers should demonstrate knowledge of health insurance and funding sources, health care services, human behavior dynamics, health care delivery and financing systems, community resources, ethical and evidence-based practice, applicable laws and regulations, clinical standards and outcomes, and health information technology and digital media for effective, competent performance.

Future articles will cover other changes in the Standards.

Hats off to CMSA for developing and revising these important standards for the discipline of case management!

Making Meaning out of Avoidable Days: Part II

This article appeared on RACmonitor.com on December 14, 2022

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In early December I asked our listeners if they knew their top avoidable day reason and if they were willing to chime in with some answers during our live chat segment. Today, I am happy to follow up on many of the responses that I received and thank you so much for those contributions. 

The responses aligned with three main categories. Delays related to transitions to the next facility, whether that be a skilled or psychiatric placement. Delays related to family decision-making and social factors. And delays related to internal processes such as not having MRI services on weekends or limitations with consulting specialists.  

Although I cannot review all the specifics, I think it is important to note that attribution matters and the only way to solve these problems is to ensure you are capturing enough detail to do something with the information.  Enough days calculated for delays in weekend MRI services is likely justification to convince the leadership to hire another radiology technician.   

When it comes to post-acute authorizations, I would suggest a deeper look.  Is the delay related to the insurance company being slow in their process as reported by the skilled nursing facility (SNF)?  Or has the SNF just told you that is the reason when it is an internal issue on their part.  The SNF may only look at admission packets once a day or are sending out authorization requests to another department that is likely centralized and in another time zone. Or maybe they are telling you it is because of the payer, but when insurance is called, you confirm that nothing has been received.  What is later discovered is the SNF has accepted the referral under ‘payer authorization’ but really does not have a bed available and they just did not want to lose the referral to another facility. 

Dig deep and get to the root of the problem.  Maybe the case manager is not proactively planning for SNF with clear evidence that the patient meets medical necessity for placement.  Has patient’s medical necessity been confirmed in the documentation that was sent over to the payer and SNF for placement requests? 

Once the source is evaluated, move into action. If one can discern the cause is the payer, request adjustments in the contract to improve these delays or request additional per diem payments while patients sit in the hospital.  If it is the SNF, call this to their attention and discuss with their leadership how you can establish a more streamlined referral process to guarantee a smooth patient transition.  If it is because of the case management team, it may be time to complete more training or look at department process improvement efforts. 

In all of this I say to our listeners you are not alone, nor do you need to accept that this is your permanent reality.  Change can occur! 

With that I would like to ask our listeners, are there efforts at your hospital to decrease your avoidable days?

• Yes

• No

• Unsure

• 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.

HINN 12 and What is Next After A Medicare Patient Has Appealed Their Discharge

This article appeared on RACmonitor.com on January 18, 2023

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One cannot place liability on the patient without a safe discharge plan in place.

Case management takes on many roles within the hospital setting, but one scenario that typically makes us stop and pause (and maybe add a sigh) is the process required when a patient appeals their discharge. The questions that follow may begin with:

• What are our next steps?

• Is the patient required to begin payment for the stay?

• Can we discharge the patient during the appeal process?

• How will the hospital be notified of the appeal determination?

Let’s discuss these questions and solutions to prevent or simplify this seemingly painful process. To begin with, the Hospital Issued Notice of Discharge (HINN-12) process is utilized as the tool and resource for Medicare patients who may be appealing their discharge.

Medicare has given us the HINN tool to be used for reimbursement of a continued hospitalization, after the patient refuses a safe discharge in place. If the patient loses their appeal with the Quality Improvement Organization (QIO), the patient will become financially responsible for the continued stay. This process applies to any patient who qualifies for the Important Message from Medicare (IMM), including Medicare Advantage (MA) plans, Medicare as a secondary payer, or dual-eligible (Medicare/Medicaid) recipients.

Commercial payers may not have an equivalent tool or a concurrent review after a discharge appeal that leads to the patient being financially responsible. Often, these patients remain in the hospital past their discharge date, leaving the hospital without the ability to enforce a discharge or financial responsibility for the continued stay. The HINN-12 process should be seen for what it is: a great tool to keep the discharge process moving while continuing to work with the patient and family to agree to a discharge plan.

STEP 1: THE MEDICARE PATIENT HAS APPEALED THEIR DISCHARGE OR THERE IS AN EXPECTATION TO APPEAL.

The day has come! Case management has worked hard and has an accepting skilled nursing facility (SNF) or post-acute placement plan in place for the discharge today. The hospitalist has either written a discharge or the intent to discharge (the initiation of the appeal process no longer requires a written discharge order). The first question that I always ask the case management team is, “why is the patient appealing?” It is likely that the patient and/or family has an unmet need or fear that is driving the appeal. My recommendation is to get to the bedside ASAP and bring your listening skills before they call 1-800-MEDICARE. Patients and/or their families are likely appealing the discharge related to a fear they may have based off an unmet need, whether it’s realistic or unrealistic. They may have had a spouse die at a SNF or have heard that people that go to a SNF, but never go home. They may be afraid to let home health into their home or they may feel safer in the hospital due to their lack of home support.

Regardless of the reason or the validity of the fear, the concern is real to them. Listening and working to resolve concerns can prevent the appeal from occurring. A different SNF closer to family may make them more comfortable. Maybe accommodation can be made for a family member to stay with the patient in the facility to ease the transition. I would estimate that case management visits to ensure a collaborative discussion and patient transition will help avoid a discharge appeal, and it is well worth case management’s time to enhance the patient’s satisfaction level with the discharge.

STEP 2: THE PATIENT HAS APPEALED. WHAT DO WE DO NOW?

Ok, the patient has appealed, so on to the next steps. Maybe you have not had a Medicare appeal recently, or maybe you have never handled one. What will happen next? Well, your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) is going to reach you by the method your hospital provided to them.

The two QIO organizations are Kepro and Livanta, and they are assigned by state. The QIO has a designated contact at your facility where they will send the appeal letter and required document request. The requested documents need to be returned to the QIO within 24 hours. Due to this timeline, the method by which the QIO letters come in should be monitored by someone in case management at all hours that the department is operating. If the requested documents are not returned by the hospital to the QIO in the requested timeframe, the QIO will agree with the patient on the appeal. This will prevent the hospital from proceeding with the HINN process or attributing financial liability to the patient, thus limiting the hospital’s ability to move forward with discharge.

The documentation request from the QIO will include the IMM that was signed by the patient and a copy of the signed Detailed Notice of Discharge (DND). The DND letter can be found on the Centers for Medicare & Medicaid Services (CMS) website and must be given to the patient when they appeal to the QIO. On the DND notice, you will indicate why the patient’s hospital stay is no longer required and why Medicare payment for their stay is ending due to lack of medical necessity.

To proceed with the discharge appeal process, case management must ensure that there is a safe discharge plan in place throughout the appeal process. If at any time the safe discharge is no longer available, the patient will remain in the hospital. An example would be that the patient is expected to discharge to a SNF and the bed is no longer available, and there is no other safe discharge backup option in place. You cannot place liability on the patient without a safe discharge plan in place. One of the most common questions asked is this: is the patient required to remain hospitalized during the appeal? The answer is yes. The appeal occurs because the patient feels they are not ready for discharge, therefore they remain in the hospital until the appeal is complete.

STEP 3: YOUR QIO AGREES THAT THE PATIENT IS APPROPRIATE FOR DISCHARGE. WHAT HAPPENS NOW?

The QIO has 24-48 hours to make a decision on the appropriateness of the discharge. My experience has been that in most cases, if you have submitted the documents they have requested and confirmed a safe discharge plan, the QIO will side with the hospital. Once you receive the QIO decision, you can inform the patient that their responsibility for the hospital bill will begin on the following day at noon, if they have not been discharged from the hospital by that time. The letter provided to the patient should outline the reason they no longer meet medical need for inpatient hospitalization, the date upon which they will be financially liable, and the estimated total or average daily cost, beginning from the date of noncoverage. This letter must be signed and dated by the beneficiary. If they refuse to sign it, you can indicate that on the form. This can be a difficult conversation to have with a patient and/or family. My approach has been to take the manager/director of patient billing along to meet with the patient. They should bring information on the expected daily costs to begin the next day at noon. Be sure to have conversations with your leadership once this HINN-12 process begins. There will likely be lots of discussion prior to asking the patient to pay for their stay regarding how your organization will decide to handle that sensitive topic.

STEP 4: WHAT? A SECOND- AND THIRD-LEVEL APPEAL?

Yep! A patient has the right to a second- and third-level appeal if they continue to refuse the discharge plan. But after the patient loses the first-level appeal, the financial liability falls onto the patient if they choose to remain in the hospital. The second-level appeal process for Medicare Fee-for-Service (FFS) will take 1-3 days for a response, for a hospitalized patient. The medical record review will be the same information as submitted on the first version, but will be reviewed by a different physician than during the first appeal review. On the second review, the family is permitted to submit pertinent documentation. A second-level review for a MA plan may vary, dependent on the payers. Reach out to the MA plan on all appeals to verify their appeal process and documentation requirements.

The third-level review will occur as an Administrative Law Judge (ALJ) hearing. The office of Medicare Hearings and Appeals (OMHA) is responsible for administering  ALJ hearings. MAXIMUS is the Federal Services for the Part C Independent Review Entity (IRE). Any party in the appeal process may appeal to the Medicare Appeals Council if they are dissatisfied with the outcome of the ALJ decision. To dig into more details on these higher levels of appeals, go to https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/BFCC-QIO-Review and dive into the QIO manuals and everything related to the appeals process.

Hospitals should have an outlined policy for how they address patient appeals, as case managers will want to ensure that they are trained regularly regarding this process. Patients appealing their discharge should not be a hospital common occurrence; however, we are seeing it occur more frequently in our collaborative health systems across the country.

Reviewing these cases will be helpful to make sure that the necessary steps are taken to ensure compliance, and to see if this could be avoided in the future.

Should I Hire Someone Without Case Management Experience?

This article appeared in the Case Management Society of America Blog in November 2022. You can find it here: https://cmsa.org/should-i-hire-someone-without-case-management-experience/

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Now that we are settling into what feels like our new normal, staffing is more of a challenge than ever before. Recently, I had a discussion with hospital leaders regarding the recommended amount of experience when hiring a new case manager. Once the conversation began, there were varying opinions with a focus on ensuring the development of a case manager who works as an advocate for the patients with an understanding of the business of healthcare. Ideally, leaders look for an applicant with 3-5 years of case management experience. We also hope for several applicants to interview and choose from. Unfortunately, in the current market, we are lucky to have one applicant for a position in the first few months that it is posted. While experience is always preferred, an applicant with the right qualities can succeed. The focus needs to be on core curriculum and training from a tenured staff who can educate, orient and offer ongoing mentorship.

So, the question I pose is: can you hire a new graduate or someone with no previous experience as a case manager? My answer is yes, and before you gasp out loud, there are considerations and steps that can assist in hiring the right person with the right qualities to succeed in the demanding role. Below, we will discuss how you can determine those qualities during your search, focus on a successful orientation and develop a program that supports personal growth and advancement as a case manager. For the record, I agree that an experienced case manager is always best. The BUT is that, like the housing market, the inventory is low and the demand is high so thinking outside of the box is necessary to meet the needs of our patients and our communities.

Interviewing For Your Next Case Manager

While completing your interviews, you must think of the qualities required to be an effective case manager. Skills can be taught, but attitude and work ethic must be considered equally as attributes to success. Core qualities are required for an individual to advocate for a patient, confidence to interact with physicians and be assertive enough to facilitate a group in conversations with multidisciplinary teams. Case managers problem-solve under stressful situations and need to work autonomously.  Hiring for these qualities and the ability to handle difficult situations will benefit of the patient, team members and the organization.

While interviewing, use questions that identify excellent communication skills led by critical thinking and self-confidence. Is this person going to be able to multitask throughout the day?  Can they identify and prioritize patients who are ready for discharge today and ensure the plan is in place? The ability to quickly adapt to changes in the plan and redirect the focus required for the patients’ discharge takes patience and skill to prevent discharge delays for complex patients.

Questions that can be asked to look for this candidate who has the attributes that you are looking for may be:

• Tell me about a time when you realized you needed to make an improvement in your communication skills. How did you manage it?

• Tell me a time that you worked with a person whose personality was the opposite of yours. How did you manage your relationship?

• How do you organize your work to ensure that you are the most effective and productive?

• What have you done that was innovative?

Orientation Success and Outcomes

We were not born case managers and we all started somewhere as a new grad. The variation lies in how effectively we were trained when we began. My first job was on a long-term care unit. I was 22 and I looked about 17! I was told that I would receive 6-8 weeks of orientation. The first night, I received orientation and worked alongside a nurse. The second night I was “on my own” due to staffing and the need for coverage of a patient assignment. And the third night I was the charge nurse because she had called off and everyone else working had floated from another unit. Thank goodness, I returned to an orientation schedule the following week. But now, as a leader, I see how the system failed me as a new grad and the lack of support for me to receive proper training. Not to mention patient safety!

Orientation of a new grad, whether as a nurse or social worker, will require additional time to orient than those with prior experience. A case manager boot camp curriculum and education discussing best practices for transitions of care, utilization review, regulatory requirements and need to know items for your community will benefit those coming into the profession. For new social workers, an additional boot camp piece related to key medical wording, diagnoses and disease processes would be beneficial due to their lack of medical education during their social work program.

Retaining Staff and Investing in Staff Advancement         

The knowledge and skills that an organization arms their staff with will pay off through the care provided to the patient and the understanding of the continuum of care for best patient outcomes. Those of you reading this article are involved in the CMSA, which means you are putting in the effort to continue to learn by participating in this community. But are your team members involved? Are those who report to you involved? And if not, why not and how to we get them involved? Think of what can be done to get more of your staff involved in case management associations and certification once eligible. Certifications offer case managers the ability to promote their advanced knowledge to their patients, families, and colleagues. It reflects a higher level of commitment and encouragement of these advances which assists solidify the future of this professional’s path within the case management profession.

The changes in hiring challenges don’t appear to have an end in sight and there won’t be an easy fix to finding experienced team members. Maybe you will not decide to hire new grads but do look at your requirements in your job descriptions. Could you lower the required years of experience to attract more talent? What can you do to adjust your orientation program to have a more comprehensive approach to meet the needs of a new hire with little to no experience? We need to broaden our scope to meet the demands of this new hiring market. Good luck to you all!

Bio: Marie Stinebuck MBA, MSN, ACM is the Chief Operating Officer of Phoenix Medical Management, Inc., the leading case management firm. She has practiced as a nurse for the past 25 years with 17 years in the field of case management and has served in several roles in senior leadership roles in Case Management. Marie has also authored numerous articles, is a weekly contributor on Finally Friday and is a Board Member for the Arizona ACMA.

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

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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

This article appeared on RACmonitor.com on December 7, 2022

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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

This article appeared on RACmonitor.com on November 16, 2022

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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

This article appeared on RACmonitor.com on November 9, 2022

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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:

1. 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;

2. 24/7 staffing to address emergency medical care with appropriate licensed professionals;

3. Maintaining and submitting ongoing data requirements for Quality Assurance and Performance Improvement Program (QAPI);

4. 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

5. 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?

This article first appeared on RACmonitor.com on October 26, 2022

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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

This article appeared in RACmonitor.com on October 12, 2022

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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

This article appeared on RACmonitor on October 5, 2022

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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://www.federalregister.gov/documents/2022/08/10/2022-16472/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the

https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf

Looking to the Future: Striving for More Than Just Discharge Planning

This article appeared on CMSA.org on September 26, 2022

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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 article appeared on RACmonitor.com on September 20, 2022

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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

This article appeared on RACmonitor.com on August 31, 2022

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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:

Money Follows the Person | Medicaid

SDoH at the Intersection of Healthcare Quality

This article appeared on RACmonitor.com on August 24, 2022

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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:

Using Administrative Codes to Measure Health Care Quality | Health Care Economics, Insurance, Payment | JAMA | JAMA Network

https://oig.hhs.gov/oei/reports/OEI-03-17-00474.pdf

https://www.commonwealthfund.org/blog/2022/taking-stock-medicare-advantage-risk-adjustment