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Reduce one-day stays when observation is better
Transitions were not optimal
Hospitals sometimes fail to transition patients to the optimal level of care, which can create issues with quality of care and reimbursement.
A recent quality improvement project found that most one-day stays in a hospital were related to patients having chest pain symptoms. And many of these one-day stays originated in the emergency department and were unnecessary, an expert says.
The project found that patients were transitioned inappropriately, leading to higher costs and Medicare claims denials.
"We worked with 17 hospitals in a process improvement effort," says Mary Helderman, RN, CPUM, an oncology nurse in Terre Haute, IN. Helderman wrote a quality improvement report on one-day stays when she was the project coordinator for the Hospital Payment Monitoring Program (HPMP). HPMP, which had the goal of measuring, monitoring, and reducing the incidence of improper fee-for-service inpatient acute care Medicare payments, was disbanded in August 2008.
"We took a sampling of patients from the 17 hospitals and found that 79.9% didn't meet admission criteria," she recalls.
"So that's a large percentage, and the estimated overpayment for those amounted to over $600,000," Helderman adds. "When we looked at charts at three different intervals for 17 hospitals, there was an estimated overpayment of $1.5 million over a two-year period."
The baseline sampling was retrospective, and the other two samples were done before the claims were submitted, she says.
The idea was to have physicians clearly write whether they wanted a patient to have an observation stay or to be admitted to the inpatient acute area, she says.
"We found that maybe when the physician would write an admit to outpatient care, the person registering the patient would see the word 'admit' and interpret it as an inpatient stay," Helderman explains.
The problem could be the forms made the patient's transition unclear, or that people were not looking as closely at the forms as they should, she says.
Some hospitals seeing this report decided to implement a case management team in their emergency departments, Helderman says. Other smaller hospitals implemented weekend coverage of case management to catch inappropriate inpatient stays before Monday morning, she adds.
"Others focused on education, educating staff on the difference between an inpatient stay and an observation stay, and they gave staff information about payment and denials," Helderman says. "Some started focused monitoring on inpatient stays to see where the gaps were in the process and to implement some changes there."
And some hospitals did concurrent chart reviews, rather than wait until patients were discharged to review their charts, she adds.
[For more information, contact: Mary Helderman, RN, CPUM, oncology nurse, Terre Haute, IN. Phone: (765) 505-0102.]