Case management affects bottom line, quality of care, regulatory compliance
Case management affects bottom line, quality of care, regulatory compliance
Challenges, opportunities abound in today's health care market
Hospital reimbursement is being squeezed from all sides. In the proposed Inpatient Prospective Payment System rule for fiscal year 2010, the Centers for Medicare & Medicaid Services (CMS) has proposed slashing the Medicare reimbursement update to account for improvements in documentation and coding and limiting reimbursement for readmissions.
In addition, the Recovery Audit Contractor program, being rolled out across the country, is aimed at recouping millions of dollars in overpayments to hospitals.
Then, when he outlined his plans for health care reform, President Obama proposed cutting an additional $313 billion in Medicare and Medicaid spending over the next decade.
At the same time, commercial insurers are tightening up on reimbursement and denying claims they used to approve.
CMs and eliminating waste
"The changing health care environment challenges hospitals to become more efficient and eliminate waste in order to continue keeping their doors open," says Joanna Malcolm, RN, CCM, BSN, senior consultant for Pershing, Yoakley & Associates in Atlanta.
That's where case managers come in, adds Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and health care consultant and partner at Case Management Concepts LLC.
"Case management is all about hospitals getting paid for services they provide, whether it's getting paid for each day the patient is hospitalized or not getting a denial for the care and moving patients through the continuum of care in a timely manner. Case managers definitely have an effect on their hospital's bottom line," she says. (For a list of ways case managers affect the bottom line, see chart.)
Case management directors often complain that they can't get additional positions because case management isn't a revenue-generating department, Cesta says.
However, she points out, hospital revenue comes from a bill that represents a combination of services, and case management is definitely one of those services.
"Case management is not any more or any less revenue-generating than any other department, and we do contribute to the hospital's bottom line," Cesta says.
CMs' impact on revenue, compliance
A hospital's bottom line is not just about money. It's also about quality of care, and that's where case managers can have a huge impact — by eliminating unnecessary admissions and patient days, preventing readmissions, and ensuring that patients receive the evidence-based care mandated by the core measures, Cesta points out.
If hospitals don't pay close attention to the care they are providing to all patients, and not just those with commercial payers, they won't be able to compete in the new health care marketplace, she explains.
"In the past, Medicare was a free ride. Now that CMS has rolled out the Recovery Audit Contractors and other initiatives, case managers need to focus just as much on Medicare as on commercial payers and optimize care for all patients," Cesta says.
In addition to optimizing revenue, case managers can be instrumental in making sure that their hospitals comply with regulatory issues, Cesta points out.
"Hospitals are not in compliance if they don't have a utilization review committee or if they don't use Condition Code 44 correctly or give the Important Message from Medicare properly. The days of being able to slip by are way over," she says.
With the emphasis on reducing length of stay, hospitals need to be fully staffed and provide all services seven days a week instead of being fully operational only five days, Cesta says.
"The next greatest opportunities case managers have to affect their hospital's bottom line is weekend coverage. All the low-hanging fruit is gone, but we still have reimbursement vulnerability with weekend issues," she says.
Most hospital case managers report that they are swamped with work on Monday because few patients go home over the weekend, and they start the week on high capacity.
'Break the patterns'
"Hospitals need to look for patterns and do something to break the patterns, such as reaching out to nursing homes to accept patients on Sundays and having a dedicated physician to write orders for discharge on the weekend," Cesta says.
It all goes back to staffing and whether the administration supports case management, she adds.
Case management directors have to make a case for the right number of people on their staff and to show management that yes, the work of case management does affect the bottom line, Cesta says.
"If the department isn't staffed properly, it's a challenge to do these things. If the case managers aren't on site on the weekends, they can't do the proactive things that positively impact length of stay and capacity issues. Instead, they're putting out fires all the time," she explains.
One of the most important things that case managers can do is to provide education to the hospital's administrative team and governing board on the role they play, says Brenda Keeling, RN, CPHQ, CPUR, of Patient Response, a Milburn, OK, health care consulting firm.
"Case management is defined very differently facility to facility, executive to staff. Often the case manager role expands because 'you're in the chart' in ways that create inefficiencies and duplication of effort. Case managers are very diligent and knowledgeable but when they have too much work, something is going to fall through the cracks," Malcolm adds.
Not only do hospitals need adequate case management staff, they need qualified case managers who are well trained and understand reimbursement issues, Keeling points out.
"Too often, case managers are nurses who may have suffered a back injury or developed carpal tunnel syndrome and are then put in the case management role without the skills or tools to do their job," Keeling says.
"With the emphasis on patient flow and readmissions, case managers must identify what patients will require at home after discharge as early in the stay as possible, and this means performing an initial discharge planning assessment on the day of admission," Cesta adds.
One way to improve throughput is to ensure that all members of the treatment team communicate well with each other, adds Joyce Evans-Bailey, RN MBA, consultant with Compirion Healthcare Solutions, a health care consulting firm with headquarters in Madison, WI.
"Working with the doctors for discharge plans during their rounds helps case managers plan the stay of the patient during the 22 hours a day that the doctor isn't at the hospital," she says.
Bailey has developed a course to educate case managers and charge nurses on the role each plays in patient care and to increase communication between the two disciplines.
"The case managers and charge nurses look at patients from two different viewpoints, but they can work together on a common goal and improve patient care," she says.
Get all the disciplines together and look at barriers to discharge, Bailey suggests.
Start on the unit that has the most admissions from the emergency department because that's where throughput is most critical, she suggests.
"Look at what happened on Day 2 that kept a patient from going home on Day 4 and brainstorm on how to overcome the barrier," Bailey suggests.
Make sure that you have basic information that will affect patient discharges, such as a phone number of a family member and what time he or she can transport the patient home, she adds.
"Hospitals often become so technologically advanced that the staff forget that important piece of discharge planning," she says.
If your hospital is tight on beds, look at the process side. If a lot of patients are staying until the early evening hours when their family members get off work, consider setting up an alternative unit for patients who no longer have acute care needs, Bailey suggests.
"If they're medically stable and can go home but don't have transportation, they could be placed in a medical discharge unit until their family can pick them up," she says.
(For more information, contact: Toni Cesta, RN, PhD, FAAN, Senior Vice President, Operational Efficiency and Capacity Management, Lutheran Medical Center, e-mail: [email protected]; Joyce Evans-Bailey, RN MBA, Consultant, Compirion Healthcare Solutions, e-mail: [email protected]; Brenda Keeling, RN, CPHQ, CPUR, Patient Response, e-mail: [email protected]; Joanna Malcolm, RN, CCM, BSN, Senior Consultant for Pershing, Yoakley & Associates, e-mail: [email protected].)
Hospital reimbursement is being squeezed from all sides. In the proposed Inpatient Prospective Payment System rule for fiscal year 2010, the Centers for Medicare & Medicaid Services (CMS) has proposed slashing the Medicare reimbursement update to account for improvements in documentation and coding and limiting reimbursement for readmissions.Subscribe Now for Access
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