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Get ready for increased scrutiny on hospital quality
Accurate data are more important than ever
As they wait to learn the next steps in health care reform, case managers should start thinking about what they need to do to get ready for the future, says Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital.
"We don't know for sure what the details of health care reform will be and what effect it will have, but we do know that having accurate data is going to be more important than ever," Cunningham adds.
Start by looking at the areas where you know reimbursement is going to be affected and determine what you can do to have an impact, she adds.
For instance, the Centers for Medicare & Medicaid Services' announcement that it intends to reduce reimbursement for preventable readmissions makes it important for case managers to pay careful attention to their hospital's readmission data and take steps to ensure that patients don't come back to their hospital, or another hospital, Cunningham points out.
"Case managers are responsible for ensuring that patients have an appropriate discharge plan that prevents readmissions. That is going to contribute to reimbursement in the future," she says.
At present, the health care reform legislation mandates that hospitals will be penalized by a reduction in reimbursement for readmissions that are not in the expected range, beginning in 2012, Cunningham points out.
"That gives us an opportunity now to aggregate data and understand why patients are being readmitted. When patients are admitted within 30 days, I recommend to case management leaders that they determine the reasons for readmission and work with the hospital's quality department on ways to prevent readmissions," she says.
If a patient is discharged from one hospital and admitted to any other hospital within 30 days, the discharge is included in the first hospital's readmission rate, she points out.
"This puts a burden on us as case managers to make sure that the patient and family education is complete and thorough. Case managers may not need to do all this education, but since we have a care coordination function, we need to assure that it is done," Cunningham says.
Already, if patients are readmitted to the hospital at any time, not just within a 30-day period, because of inadequate and incomplete care, the second stay is not payable and the hospital has to combine the bills into one, adds Deborah Hale, CCS, president of Administrative Consultant Services LLC, a health care consulting firm based in Shawnee, OK.
For instance, if congestive heart failure patients do not have documented discharge instructions about diet, how to monitor weight, and when to call the doctor, they typically come back to the hospital very quickly, possibly because they are eating the wrong things, Hale says.
"However, if the hospital has adequate documentation at the end of the first admission showing that the patient received the proper education, it can make the case for the readmission being due to noncompliance," she says.
Don't use a patient's noncompliance with the discharge plan as an excuse for readmissions, Cunningham cautions.
"We need to understand the reason for the noncompliance. Maybe the patient didn't understand the care plan or couldn't afford the medication," she says.
Case managers should make sure that patients and family members have the right education on post-acute care, that they know the signs and symptoms that indicate they should call their doctor, that they have prescriptions, that they are capable of getting to the drugstore to fill them, and that they can afford to fill the prescriptions, Cunningham says.
"Case managers have an increasingly important role in implementing the transition from the acute care setting to another level or care or the patient's home. Ensuring that the transition is well planned with the patient and caregivers, that people at the next level of care have the information they need, and that the patient has a follow-up appointment all help mitigate the likelihood of a readmission or an adverse event," adds Carolyn Scott, RN, MEd, MHA, vice president of performance improvement and quality for Premier, a health care performance improvement alliance.
Go to the CMS Hospital Compare website and see what your hospital's readmission rate is and how it compares to state and national readmissions, Cunningham suggests.
"This will give case managers an idea of how their hospitals are doing and potential areas for improvement," she says.
Case managers can have a role in helping avoid hospital-acquired conditions by taking proactive steps to identify patients who are at risk, Scott says.
"The more case managers have access to real-time and predictive data that let them know what patients are at risk, the better they are able to help their hospital's efforts to reduce hospital-acquired conditions," she adds.
For instance, if case managers are aware of which patients are more prone to various infections or who is at risk for a fall, they can be more proactive in helping avoid a hospital-acquired condition or a fall.
"It's so much better to proactively manage a complex patient at the outset than it is to deal with the implications after an adverse event," she says.
Pay careful attention to patient status and make sure that the data on the bill match what really was ordered in the patient's medical record, Cunningham says.
What typically happens is that when a patient comes into the emergency department, the physician wants to reserve an inpatient bed, so the patient is listed as an inpatient in the system. Once the physician completes the work-up, he or she writes the orders for observation services, but the patient's status never gets changed in the system, Cunningham says.
"Any data that are on the bill become part of pubic reporting, so it's critical that before the account is billed that the billing matches our order," she says.
Watch the patient's discharge status and make sure it matches where the patient actually went and the services he or she received after discharge, Cunningham says.
"Sometimes the doctor writes the order for a patient to go to a nursing home, but the nursing home puts them in a skilled bed. Hospitals are also held accountable for discharge status accuracy," she says.
Case managers can use their hospital's scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) as a guide to where processes can be improved, suggests Quint Studer, CEO of Studer Group.
Results of the 27-question HCAHPS survey, which measures patients' perception of quality of care, is reported on the Hospital Compare website.
"Everyone is looking for a silver bullet for improving health care performance, and HCAHPS is the closest thing we have," Studer says.
For instance, one question asks patients if they understand their medication and potential side effects.
If patients report on the HCAHPS survey that they didn't understand their treatment plan, it's likely that they didn't adhere to it, he adds.
"Consider that one in five patients has an adverse event after discharge and 60% of this is due to medication. Many times, it's not problems with the discharge plan that brings patients back to the hospital. It's the compliance with the plan. By using the HCAHPS data and holding staff members accountable for making sure people understand their medication, hospitals can improve clinical outcomes," he says.
As they initiate quality improvement projects, case managers are in a position to look at patients throughout the continuum of care and make sure that what happens at one level of care doesn't adversely affect another, Scott adds.
"It's great to reduce inpatient length of stay, but when your outpatient mortality or readmission rates go up, you haven't really accomplished anything from the perspective of the patient," she says.