Take a realistic approach when you plan a discharge
Negotiate with MCO or seek community resources
The days are long past when there were few limits to what a hospital case manager could recommend for a patient’s discharge plan.
Now, case managers must look at what is appropriate for patients to meet their medical needs and to get them safely to the next level of care, says Jackie Birmingham, RN, MS, CMAC, vice president of clinical design for Curaspan, a provider of connectivity and network management across the post-acute continuum.
"I’m not implying that patients’ needs have been overplanned for, but often the discharge planner asks the patient about discharge options without regard for whether the patient can afford it," says Birmingham, who has more than 20 years experience in case management and discharge planning. Discharge planning should be a partnership between the case manager and the patient, she adds.
Hospital case managers should spend time with the patients, making sure the discharge plans reflect what they need, what they’re willing to do, and what other resources they have, such as family and friends, she adds.
For instance, you may suggest that a patient change his or her dressing twice a day, return to the physician’s office at a certain time, and have a home health aide. The patient may agree to everything but then not follow through.
"Case managers need to step back and decide if the patients really need all of this. Patients will usually say yes’ to almost anything to get out of the hospital," Birmingham adds.
Case managers should assess what is safe for each patient, depending on the home situation, she adds. For instance, if patients don’t have steps in their homes and their hallways and doorways are wide enough to accommodate a wheelchair, they might be able to go home with outpatient rehab instead of being discharged to a rehabilitation facility.
Case managers are required to give patients choices of post-acute care. Instead of offering the patient a "pie-in-the-sky" list of options, assess their needs carefully and offer appropriate choices based on the patient’s needs and resources, she advises. "Giving patients choices increases the success, but they should be choices that are good for them," Birmingham adds.
You may have good luck negotiating with a managed care organization for discharge needs that aren’t covered if they may prevent a readmission or a complication because it’s to the financial advantage of the insurer, points out Toni Cesta, PhD, RN, FAAN, director of case management for Saint Vincent’s Hospital and Medical Center in New York City. "If you can argue safety and appropriateness of discharge with the third party, many times they will work with you," she says.
Medicare and Medicaid benefits are fairly cut and dried, with little room for negotiation, but sometimes private payers are willing to cover a benefit if it is covered by health plans, Birmingham adds. Since the case manager’s job is to ensure that the patient has a safe discharge, the managed care company may be willing to bend a little on certain benefits. For instance, if a patient doesn’t have a home health benefit, call the managed care company and ask for a home care evaluation, she says.
One inducement for the managed care company to cover the cost would be that you can’t discharge the patient until you know he or she will be safe at home. In other words, if the managed care company won’t authorize the visit, the hospital won’t discharge the patient.
Following the home health visit, patients know what options they will have.
When case managers look for alternative sources of funding to cover patients’ needs, they often must look to resources in the patients’ hometown, such as the local agency on aging or a state program for the elderly.
"In the United States, we don’t abandon the patient. Even the homeless have rights to some benefit," Birmingham points out. Often, it’s a matter of getting the social worker involved. "Some hospitals don’t understand the extreme value of social workers in the hospital to help get the patient ready for discharge," she says.
Case managers should involve social workers in the discharge planning so they can work with the family to find solutions to problems, Birmingham suggests.
Know who the social worker is inside and outside the hospital and involve them in finding sources of help for the patient.
Medicare’s prospective payment system for home health and nursing homes has complicated discharge planning for patients who need post-acute services, and benefits often are more limited than before.
If these agencies are reaching what they set as their maximum capacity of complex patients, they have the right to refuse to take patients who need complicated and costly care. They want detailed information up front about patients’ conditions and needs before they decide to take them.
For this reason, case managers must have a strong clinical description of a patient before they call in the home health agency or the nursing home, Birmingham says.
Sometimes, it takes a lot of juggling to get a patient safely discharged with post-acute care, Cesta adds.
For instance, Medicare doesn’t reimburse for medication. If a patient is on an expensive antibiotic, the nursing home may not want to absorb the cost, so it doesn’t take the patient.
"In these cases, we will provide the antibiotic because it’s more cost effective than keeping them in the hospital. We don’t do it very often but we have sent patients to nursing homes with medication," Cesta says. She suggests that when these types of cases occur, case managers do a cross-benefit analysis to see what is better for your facility financially.