By Jeanie Davis
In February, New York’s first COVID-19 cases were treated in Westchester County, a short train ride from Manhattan.
“Emergency plans were in place, but as the numbers grew, our facility understood that dedicated COVID units were needed,” says Camille L. Kurtz, RN, MA, vice president, clinical care management/utilization management at Westchester Medical Center in Valhalla, NY.
With an analyst’s help, Kurtz worked bed optimization for the medical center’s 654 beds that included three COVID-19 patient care units: high-need intensive care unit beds, middle-need beds, and lower-need beds. “At any point in the day, I know where COVID and non-COVID patients are and when beds are available,” she says. Most days, the hospital has more than 200 COVID-19 patients, she reports.
With COVID-19 patients, Kurtz says, “we managed with the clinical guidelines as tightly as we could, given the severity and acuity of the patient’s illness. We managed all COVID patients as if they were the sickest patients. We have to manage them tightly because of the impact on resources — that’s how COVID is different. And while other facilities were focused on getting more ventilators, we needed to be cognizant of staff and PPE [personal protective equipment] resources.”
Kurtz assigned 50% of clinical case managers and social work staff to “bench status,” working from home. If an onsite case manager were to test positive for COVID-19, that person would go into quarantine, and a bench staffer can be recalled to work onsite as need dictates.
Kurtz’s early years were in hospital nursing, followed by a 21-year stint as an insurance company case manager and leader. “CMS [Centers for Medicare & Medicaid Services] and payers have relaxed rules and regulations around authorizations for admissions during this pandemic,” she says.
However, she says, there is the possibility that admissions could be denied retrospectively (based on her experience during Hurricane Sandy). “As such, we continue with timely notification of admissions and timely clinical review submissions.”
Medicare cases will be the easiest, she adds. “Those have blanket approval, and I don’t think they will have as much scrutiny as insurance carriers will do retrospectively.”
In addition, Kurtz advised case managers to make sure the Important Message from Medicare (IMMS) and Medicare Outpatient Observation Notice (MOON) forms are completed. “Guidelines on those were not relaxed and will need to be completed for compliance,” says Kurtz.
Hurricane Sandy taught her some good lessons. “In future surveys, CMS may see that those cases were during the COVID period and ignore them; I am not sure” she says. “But with Hurricane Sandy, if those forms were not there, we were told we didn’t hit 100%. CMS didn’t relax guidelines on forms to the beneficiaries then, and I believe they have no interest in relaxing beneficiary notices now during the pandemic.”
Most of the CMS changes have been helpful, Kurtz observes. “Insurers have followed suit for the most part. But I’ve continued to get authorizations with managed care companies because of the retrospective review — they could deny the claim. While the financial impact to the beneficiary is not clear, preventing denials to our organization is important in these uncertain times.”
At Westchester Medical Center, the beds must be optimized relatively quickly, says Kurtz. The discharge planning system already in place has served them well during the crisis.
She has set up six-week rotating shifts for case managers and social workers in a discharge planning unit. When they are not rotating into those units, they are assigned a nursing unit.
Kurtz explains how it works: Two case managers and two social workers work together as discharge planners every six-week rotation. The nurse case manager sets up home care. The social worker coordinates transfers to skilled nursing facilities. All is coordinated via phone, including patient and family interactions.
When nursing and social work staff rotate their shifts, all staff have an opportunity to keep their case management and discharge planning skills sharp, she explains. “This also ensures bench accessibility if your units become undercovered because of sick calls.”
Kurtz adds: “Discharge planning has so many components. It should always be a very holistic process so there are no gaps that result in readmission. The social worker staff does a tremendous job in screening for social determinants of health that bring patients back.”
Case managers are like air traffic controllers over home discharges. “Case managers have had a challenge with home health referrals in recent times, as many home care agencies in the area are understaffed,” says Kurtz. “If we can’t get someone in the home within the first two days, we often delay discharge until we can prevent a readmission.”
During the COVID-19 crisis, discharge planning challenges have been enhanced, says Kurtz. “If a COVID-positive patient is going home, and no one can pick them up, we can’t just put them in an ambulance or a taxi.”
She coordinated with an ambulance company to provide transport for COVID-19 patients. The service picks up the patient wearing full PPE, takes them home, then sanitizes the ambulance. “This transportation arrangement has been very successful and helpful for our medical center with challenging discharges,” she says.
To date, says Kurtz, their hospital has had sufficient ventilators to manage their patient volume. But staff face plenty of anxiety, including the emotional stresses caused by social distancing. “If they’re working at home, it’s challenging, especially if they’re single because they’re not experiencing any human contact or socialization as a family would,” says Kurtz. “We focus on discharges and other inspirational stories from our staff and the community. Emotional support is available for staff via the psychiatry department’s dedicated employee support line.”
Kurtz praises the case managers and social workers, as they have adapted to the new work environment — and continue to hit all productivity and compliance targets.
“During the past five years, as this case management department reports to revenue cycle, the staff have learned the impact they have on preventing denials and improving revenue,” she says. “This has helped them value the work they do. I call them my rock stars. They are true diamonds.”