New Important Message requirements became opportunity to 'market' services

FTEs added specifically to distribute Medicare forms

The newly revised "Important Message From Medicare" is being treated as a public relations opportunity at Stevens Hospital in Edmonds, WA, where the case management department turned added requirements into a way to "sell" its discharge planning services to Medicare patients.

Concerned that the detailed instructions on patients' right to challenge their discharge from the hospital would trigger a dramatic increase in appeals, interim Director of Case Management Mary Bea Gallagher took a proactive approach.

"What we're doing is marketing our discharge planning by saying, 'Medicare wants you to know that you have the right to participate in your discharge plan,'" says Gallagher, a Seattle-based senior consultant with ACS Healthcare Solutions.

The new Important Message — which now must be signed by the patient and presented before discharge as well as upon admission — goes on to state that patients have the right to appeal if they believe they are being discharged too soon and gives the telephone number of the hospital's regional quality improvement organization (QIO), she adds.

First, however, the form used by Stevens Hospital points out that the patient's discharge plan will be instituted within 48 hours and provides a number to call regarding that plan, Gallagher notes. "We highlight both numbers, but the emphasis is that we want [the patient] to participate, and don't feel there will be a need to appeal."

Key to the hospital's approach was the decision not to assign the task of distributing the Important Message to social workers but to hire employees specifically for that job, she says.

"We took an FTE [full-time equivalent] and divided it between two people at a clerical skill level," Gallagher says. Those employees, known as case management assistants, work from about 9:30 a.m. to 2:30 or 3 p.m. seven days a week, distributing the Medicare forms to patients who will be discharged within the next 48 hours, she adds.

That includes locating the next of kin or the person with power of attorney if the patient is unable to act on his or her own behalf, and making the necessary arrangements if the patient doesn't speak English, Spanish, or Russian, Gallagher says. The Centers for Medicare & Medicaid Services (CMS) provides the forms in Spanish, she notes, and the hospital had the form translated into Russian, which is spoken by a significant segment of the area's population.

The process appears to be cost-effective, and so far there have been no appeals, Gallagher says. "Most of the hospitals in our area have opted to place this [responsibility] onto their registered nurses and social workers — and they are seeing appeals."

Whose responsibility should it be?

Assigning the task to social workers would mean paying about $10 more an hour for someone to do a job that is not his or her primary duty. "We are certain that if we left [distribution of the Important Message] to our normal case management social workers and RNs, too many cases would fall through the cracks."

Patient access employees present the Important Message form at admission, says Evita Armijo, patient access manager, except for cases in which, for example, there is an admission through the emergency department in the middle of the night.

Key to the success of the Important Message initiative has been the close communication between patient access and case management and an emphasis on ongoing education regarding the process, Armijo adds. "It's important to give the registrar as much information as possible, so they have the reason why the signing [of the Important Message] and documenting in the medical record is being done."

Focus on who needs it

Regarding the distribution of forms prior to discharge, notes Gallagher, there were two considerations: "No. 1, social workers don't see all the Medicare patients — just those who need assistance; they're responding to orders from physicians or nurses.

"My mom, who is age 69 and healthy, is likely to have only a three-day stay for whatever [inpatient treatment] she has," Gallagher says. "She's one of those patients who is likely to be missed if a social worker is left to [distribute the Important Message] because she wouldn't need discharge planning. Social workers need to focus on the patients who need them."

The other consideration was the follow-up that is required by the Medicare regulations, she adds. "If the patient is not present to sign, you have to contact them. Medicare says you can contact them by phone, but you have to follow up with a certified, return-receipt letter. That takes about 10 minutes."

This follow-up may be necessary, Gallagher explains, when a patient is sedated, in a coma or on a ventilator and no family is present, or when there is a language issue. "There are a lot of patients who have no local family but may be admitted from a nursing home or an adult family home."

In one instance, she adds, a patient was in the hospital with a poor prognosis, "but both of his sons just dislike hospitals," so hospital staff had to send them necessary information by mail.

Another case in which follow-up could be required is when a patient is initially admitted as an outpatient, but something goes wrong during outpatient surgery, and the person's status is changed to inpatient, Gallagher says. "If they're only here 36 hours, they may [be discharged] before we get everything organized and out to them."

"Our concern was that if we didn't hire someone for customer service skills and detail organization, then we're relying on a social worker with other primary concerns to take care of all of these instances and all of the follow-up," she adds. (See examples of Important Message communications - Script for Discharge Anticipation, Script for Admission, Late Notice Letter for ER Admit and Discharge.)

Anticipated appeals haven't happened

Although there have been no discharge appeals at Stevens Hospital since the new Important Message requirements went into effect, there was a case of an "almost appeal," Gallagher noted. The 84-year-old patient met with the discharge planner and the patient's girlfriend, also 84, who suggested that the patient come home with her, and that home health services be arranged.

While the man initially agreed, he later told staff that he didn't want to put the burden of his care on the girlfriend, but didn't want to tell her that he didn't want to go home with her, she adds. "The case manager told the girlfriend that we felt that a skilled nursing home was a better option, and that we could work out the details."

Gallagher says she had anticipated — and so far has been happily proved wrong — that there would be a significant number of discharge appeals when the new rule became effective, and that most would be prompted by family and caregiver issues.

It's easy for family members reading the language required by the revised Important Message, she notes, "to come to the conclusion that it's no pain for [them] to ask for another few days and let the patient stay in the hospital."

Even if the appeal is lost, Gallagher adds, they've still gained some time before their responsibility for post-acute care begins.

"We expected the bulk of our appeals to come from family members, [as in], 'Dad wants to come home and I'm not ready,'" she says. "We did have one person say [to a parent], 'You can't come home today — I have plans.'"

In anticipation of those discharge appeals being generated, Gallagher notes, she prepared a spreadsheet showing the estimated cost to the hospital of handling them. ( See chart.)

The hospital was a bit late springing into action regarding the revised Important Message rule, Gallagher says, because of an initial lack of clarity on the changes in procedure that would be needed.

Gallagher arrived in mid-June — about two weeks before the effective date of the new rule — for her tenure as director of case management, and on June 18, attended a session on the rule's implications, sponsored by the hospital's QIO.

At that point, she adds, they outlined exactly what would be required. Up until then, the hospital staff's understanding from a letter they had received from the QIO was that "we would just give [a notice] at admission and with the discharge packet," Gallagher notes. "We had to totally revise our vision, and we started with the admissions on July 1. It was a Sunday, so the discharge notices didn't have to start until Tuesday, which was followed by a holiday."

A memorandum to clinical staff from the hospital's case management, patient access, and medical records departments outlines the plan that was devised for implementing the new ruling:

1. Patient access staff will deliver the Important Message to all admissions, including ED after-hours, outpatients who become inpatients, and late insurance verifications. Medicare stickers will be placed on the charts to help identify patients who will require notice of anticipated discharge.

2. Morning multi-disciplinary "huddle" will be used to identify inpatients with known plans to be discharged within the next two days.

3. Case management administrative support will create the Important Message in anticipation of the discharge, present it to patients for signature and date, and file the forms in the medical record. When the patient is not competent to comprehend his or her rights, a family member will be located and presented with the notice per Medicare guidelines.

4. Questions from the patient or family members will be addressed (also noted on the Important Message papers) as follows:

  • Clinical questions to case management at (phone number listed);
  • Appeal process questions to QIO at (phone number listed).

5. After-hours discharge decisions where the patient was not notified within the past two days will be addressed by the charge nurse as part of the discharge process. Medicare stickers will be placed on the charts to help identify patients who will require notice of anticipated discharge.

6. Appeal processing will be done by:

  • Case management for detailed clinical listing of medical discharge reasons;
  • Inpatient unit designee for medical record copies due to the patient (upon request) and to the QIO.

The memorandum points out that if the patient's status changes, and an anticipated discharge is delayed, another Important Message must be given within two days of the new date of expected discharge. That means, it adds, that the patient could possibly receive multiple notices of anticipated discharge.

The memo begins by explaining that the new Important Message is more specific in its wording on appeals, and specifically addresses discharge planning, as well as noting that the Important Message cannot be given routinely to patients as part of the discharge packet.

The procedure to follow if a patient has concerns about being discharged too early is outlined in the memo, which explains that the patient should register an appeal with the hospital's regional QIO.

If the patient does appeal, the hospital will be notified by noon the following day, the memo goes on to explain, and must provide the QIO with a copy of both a Detailed Notice of Discharge and the medical records by noon of the next notification day. The QIO will respond with a decision on the appeal by noon of the day following receipt of the information.

The patient has the right to remain in the hospital during the appeal process, the memo states.

'Right people, right work'

The Important Message process developed at Stevens Hospital is in line with the philosophy she followed throughout her tenure as interim case management director, Gallagher notes. "My key phrase while I've been here is, 'Make sure the right people are doing the right work.' Nurses should not be doing family counseling and social workers should not be doing clerical work."

Gallagher's advice to any provider that has not adjusted to the new rule is that it is worth the clerical wages to pay someone to pay attention to its implementation.

"If you pull a social worker with a caseload of 20 to 25 patients to do it, [he or she] would be spending about an hour a day," she notes. "That means not working on discharge planning for patients, which means length of stay will go up and not for a good reason, [but because] we didn't have time to look for a bed, or find home health services."

At Stevens Hospital, Gallagher says, about 50% of the patients are on Medicare — "that's 10 patients a day" — and account for about 41% of the hospital's revenue.

The investment in clerical help to distribute the Important Message is also "so worth it" because of the high penalties from CMS that can be incurred if it is not implemented correctly, she adds.

"They say they will audit and I believe them."

(Editor's note: Mary Bea Gallagher can be reached at MaryBea.Gallagher@acs-hcs.com. Evita Armijo can be reached at earmijo@stevenshealthcare.org.)