Access Management Quarterly: Script 'introducing' DPs aids in 'Message' delivery
Script 'introducing' DPs aids in 'Message' delivery
Two audits also part of process
Two new auditing processes and a script for "introducing" discharge planners to their patients are the latest innovations at Stevens Hospital in Edmunds, WA, part of its response to the revised "Important Message from Medicare" (IM).
The hospital's program to turn the new requirements into a way to market its discharge planning services to patients has had excellent results, says Mary Bea Gallagher, a Seattle-based senior consultant with ACS Healthcare Solutions who recently completed a stint as director of case management at the facility.
Not only did an anticipated increase in discharge appeals not materialize, Gallagher notes, the hospital's customer service initiatives have received positive feedback from patients and tools put in place to aid the process have had unexpected side benefits.
"To date, we have had two appeals, both of which failed and both of which were instituted by families and not supported by the patients," she says.
The revised IM — which must be signed by the patient and presented upon discharge as well as upon admission — explains that patients have the right to appeal if they believe they are being discharged too soon and gives the phone number of the hospital's regional Quality Improvement Organization (QIO).
Two discharges appealed
In both instances in which discharges were appealed at Stevens Hospital, Gallagher notes, the impetus came not from the patient but from family members and had more to do with family scheduling issues than with concerns about the patient's readiness to be released.
In one case, she says, the patient's son called and said the hospital couldn't send his elderly father home because the family was at a resort on Puget Sound over the Thanksgiving holiday. Not only would they not be there to care for the patient, but they also couldn't look at skilled nursing facilities (SNFs), Gallagher adds. "They gave that as the reason [for the appeal].
"Another case was similar," she recalls. "The [patient's] daughter said, 'If I take Mom home now, I don't know what I will do with her on Thursday because I have to go on a business trip.'"
At that point, Gallagher says, the woman had not been in the hospital the required length of time to qualify for placement in an SNF, so the daughter wanted her to remain an inpatient long enough to qualify. The patient, she notes, was saying, "Please, can I go home?"
Days spent in the hospital awaiting the outcome of an appeal do not go toward meeting the SNF requirement, but the Medicare fiscal intermediary does not have a tracking mechanism in place that makes that distinction, Gallagher points out, "and the woman was smart enough to figure that out."
Regarding the patient who needed to be discharged during the Thanksgiving holiday: When the son was told that his father didn't medically qualify to stay in the hospital, she adds, "his answer was, 'I'm an attorney.'"
Although QIOs are looking at appeals from the patient's standpoint and even then finding very few that hold up, Gallagher says, hospitals still must deal with "people who know how to game the system" as well as huge expenses resulting from the appeals.
The word from the Centers for Medicare & Medicaid Services (CMS), she notes, is that "nothing can change in less than three years. So it comes back to the hospital to figure out how to reduce the number of appeals."
Hospitals are left with little recourse, Gallagher says, "other than tactics like ours such as selling the discharge planning process and [creating] a happy discharge plan."
One of the reasons the new "sales pitch" for discharge planners at Stevens Hospital is working, she suggests, is that it addresses certain patient concerns earlier in the hospital stay.
"We picked up from the questions that patients were asking that there was a sense of anxiety around the need to look for an SNF [and other discharge-related issues], especially if the family was far away," Gallagher adds.
While these concerns don't typically come up during admission, when patients "are just signing anything they can" to complete that process, she says, they often surface after the patient has been in the hospital a couple of days and has had time to settle in.
"Patients have had time to recover and think, 'Who will help me with discharge planning?' It may be that they haven't met the discharge planner yet."
Under the new procedure, Gallagher explains, discharge planners write an introduction containing information about themselves they want the patient to know. That document is used as a script by case management assistants who deliver the discharge notice, she adds.
In some cases, there are nurses who work with the discharge planners as a team, Gallagher notes, so an individual might write an introduction for herself and one for her team member.
"This provides a resource that gives the case management assistant a ready answer and has been very valuable in reducing anxiety," she says. The script might, for example, go as follows:
"Marlene Higgins is your discharge planner. She has been with the Stevens Hospital social work department for 17 years. She has a lot of valuable community contacts and has helped more than 7,000 people with their discharge planning. I know you will appreciate her understanding and skill."
The assistant may add that if the patient likes she will be happy to print a digital photograph of the discharge planner, "but she will be in to see you within the next 48 hours, so you will meet her then," Gallagher says.
The introductions — instituted in November 2007 — have been very effective not only with "selling" the discharge planning process, but in assuring patients that it's going to happen, she notes, although the discharge planning staff didn't see the advantage at first.
"They said, 'Why don't you just pass out our business cards?' We kind of forced them into it, saying, 'The case management assistants can't sell you if they don't know how long you've been here, how many patients you've helped, and what your biggest asset is.'"
Armed with the information, patients already are sold on the discharge planner when she walks in the door, Gallagher says. "Patients don't normally ask about you when you're standing in front of them, but they will ask someone else about you."
'Delivery components' reviewed
Another tool implemented to streamline the delivery of the IM at Stevens Hospital is an audit process, begun in September 2007, which examines all the components that make up the delivery of the form.
Components that are reviewed include not only signature and date, Gallagher says, but whether the patient's name is legible and whether the physician's name and the account number are on the form. The audit also addresses issues that often require a lot of time to chase down, she adds, such as: "If the patient was not available, did you contact the next of kin or the person with power of attorney?"
The audit goes on to look at whether certain information was documented and whether a required certified letter was sent and returned, Gallagher says. "The audit is done once a week by the lead case management assistant."
If the discharge planner ends up having to find the answers later in the process, Gallagher notes, "that is time that is not spent discharging people."
In November 2007, she says, the hospital added another IM review — looking at certain "electronic deficiencies" from the medical record standpoint.
"Before release, we tally up the deficiencies and see who is responsible for them," Gallagher explains. "Every day, but especially on Monday, there is a list [printed] of those patients who didn't have an [initial] Important Message in their charts or who didn't have a discharge Important Message."
The latter deficiency means that the patient got away without receiving the second notice, she says.
"We use the deficiencies [audit] to verify that the process is strong," Gallagher notes. "There are steps in place to catch these problems before the week is out," she adds. "Not more than a couple of days pass before we get notice from medical records [staff] that we missed somebody.
"Once we investigate, we often realize it is a process problem," Gallagher says. "Maybe the [IM form] was scanned into the electronic record but not put in the paper record, or it was sent up [to the nursing unit] in a tube and a nurse set it aside without putting it in the record. That is an education problem."
Reaching all patients
It is the policy at Stevens Hospital to contact patients who do not receive the IM to make sure they know they still have 30 days after discharge to appeal, she points out. "We get thanked pretty often by patients for being concerned about letting them know they have a right to appeal."
That practice remains in place, she adds, despite a request from the facility's QIO that the letters not be sent after discharge. "We don't send out many, but we want to make sure they have the 30 days."
There has never been a call from a patient regarding a possible appeal as a result of the letters, she says, probably because of the way the hospital presents the Important Message.
At some facilities, the notices "are just handed" to patients, Gallagher notes, "and in those cases, the QIO may get calls. Our presentation is more thorough. We say, 'If there are any questions, call us, and we'll send someone up to talk to you.'"
Although the hospital's after-discharge letters have not prompted inquiries about appeals, she adds, an unexpected result has been that patients have called to give feedback.
"They use the fact that our phone number is on [the letter] to say, 'I'm happy to sign this, and I just wanted to let you know I had a great stay in the hospital' or 'the discharge planner made arrangements for all these things.'"
(Editor's note: Mary Bea Gallagher can be reached at [email protected].)Two new auditing processes and a script for "introducing" discharge planners to their patients are the latest innovations at Stevens Hospital in Edmunds, WA, part of its response to the revised "Important Message from Medicare" (IM).
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