Hospital trains CMs on IMs, HINNs

Formal process ensures no one is missed

The administration at Scottsdale (AZ) Healthcare System thinks it so important for the Important Message from Medicare (IM) to be delivered correctly that all case managers go through extensive training on when and how the IM should be given to patients.

"We don't take the IM regulations lightly and have established a formal process for delivering the IMs and making sure patients and family members understand them. Otherwise, everybody may think someone else is talking to patients, and issuing the notices may fall through the cracks," says Karen Ford, MSN, RN, director of case management.

The course includes a demonstration video that shows the right way and wrong way to deliver the IMs, along with a series of PowerPoint slides. Following the training, case managers take a competency test. If they score 80% or better, they receive a certificate that goes into their file and shows that they are competent to discuss the IM with patients.

Case managers at Scottsdale Healthcare also go through training on how to deliver the Hospital-Issued Notice of Noncoverage and receive a binder with details on how and when to deliver the notices. "We don't use the HINN notices very often. We continually train our supervisors to guide case managers through the process to make sure we follow the Medicare regulations and stay on track," she says. Case management supervisors record it in the software system whenever the hospital issues a HINN letter. The hospital has prepared a training manual that instructs case managers on how to deliver the IMs and the HINNS.

The hospital's registration staff give patients the initial IM when they register. Case managers present the second IM two days before patients' anticipated discharge.

Because there are fewer case managers covering the hospital on weekends than during the week, the Friday case managers focus heavily on defining who is likely to go home over the weekend and giving those patients the IM letter. "Since the coverage is not as robust during the weekend, that was when we might miss giving an IM, so we take a proactive approach on Friday to avoid missing anyone," she says.

The case management department has prepared a script that case managers use to talk to patients and family members about the anticipated discharge date, which often is within 48 hours.

The case managers spend about 15 minutes explaining the IM letter if the patients are awake and alert. Discussions with frail elderly patients may take up to 35 minutes. If patients are still confused about the meaning of the letter, the case managers give them a copy of the Medicare publication that explains the Important Message.

When they deliver the IM, case managers document it in the hospital's electronic documentation system. At the end of every week, Ford runs a report to track whether the IM has been given to every patient in case someone falls through the cracks. She conducts a chart review audit to ensure that the signed IM letter is included. "When we first began conducting the audits, we found that information technology was not scanning the IM letters. Now, the case managers put a copy of the IM in patients' charts and give a copy to their supervisor. If the audit shows that an IM letter is missing, we can upload it into the record," she says.

Scottsdale Healthcare System experiences a patient appeal of a discharge less than once a month. The majority of appeals of a discharge are from family members who are coming in from out of town and aren't prepared for the patient to go home, Ford says.

Ford estimates that 99% of the time, patients and family members appeal their discharge because of lack of communication by the treatment team. Many times, they were expecting the stay to be longer, that more tests were needed, and that they'd have time to get the home ready for the patient's return. "We focus on strong communication with patients and family members to eliminate surprises, and we have worked with our hospitalists and surgical team to reinforce the length of stay. We have found that if we are upfront with patients from the very beginning and explain their anticipated length of stay, they are prepared to be discharged when they no longer meet inpatient criteria and don't appeal their discharge," she says.

When the QIO notifies the hospital that a patient has appealed the discharge, the hospital gives the patient a Detailed Notice of Discharge, which explains why the services no longer will be covered. The notice includes an estimate of the cost-per-day that the patient will be responsible for if the QIO denies the appeal. The cost estimate is provided by the hospital's financial services department. While the appeal is pending, the case management staff continue to work with the family and patient on discharge options.

"We tell them that they are welcome to stay but that if the QIO agrees with us, they may have a change in coverage by Medicare and be responsible for a portion of the inpatient stay. Very few patients want to stay when the QIO agrees that they no longer meet criteria," she says.