Critical Path Network

Proactive approach to comply with new IM rules

'Red Alert' notifies nursing of Medicare beneficiaries

Faced with almost 50% of its patient population receiving Medicare benefits, Berkshire Medical Center in Pittsfield, MA, took a proactive approach to comply with the revised Medicare regulation requiring hospitals to give patients the Important Notice from Medicare, informing them of their right to appeal their discharge.

A multidisciplinary committee came up with several strategies for complying with the requirements including a "Red Alert" sheet in the patient chart that notifies staff the patient is a Medicare beneficiary, and a three-part form containing the Important Message to cut down on the number of copies of the form staff have to make.

"When the process began, we knew that it wasn't something case management could do independently. We knew we needed to work with other parts of the system, including rehabilitation, behavioral health, and the access department," says Jane Reed, RN, CCM, director of care management.

Before the new regulations went into effect July 1, 2007, the access department had given patients the Important Message and checked off that the patient had received the document.

"What changed was that we had to review the discharge appeal rights with the patients, make sure they understand their rights, and require them to sign the form," Reed says.

The medical center created a steering committee that met for a few weeks to map out strategy and plan how to implement the new requirements across the continuum. The committee included the rehabilitation director, the behavioral health director, the access director, bed placement manager, associate clinical director, and supervisor for the shifts that occur when case management is not covering the hospital.

"We wanted to have all the right people involved when the requirement started. Issuing the Important Message is not just a responsibility of the access staff and case management; nursing needs to be involved as well," Reed points out.

When the case manager isn't in

One issue the committee tackled was how to make sure that the follow-up Important Message is given to patients when case managers were not in the hospital.

Case managers at Berkshire Medical Center are on duty eight hours a day and seven days a week and are not involved in discharge planning when patients are going home without services. In those cases, the nurses are responsible for the discharge instruction.

"In other cases, the doctor may come in late, when the case manager has left the floor, and the patient doesn't get the letter before discharge. Many of our surgeons are in the operating room all day, come in and discharge the patient in the evening when the case managers have gone for the day," Reed explains.

The committee realized at the beginning that nurses don't automatically know which patients are Medicare beneficiaries because they don't customarily review the face sheet in the chart, which includes information on the payer source.

"We wanted to find a way to make the information that this patient needs to see the Important Message from Medicare documents readily available to anyone who opens the chart," she says.

The team came up with a "Red Alert" notice, a red sheet of paper that goes in the chart, right behind the admissions face sheet, alerting staff that the patient is a Medicare beneficiary and should receive the Important Message documents.

The committee held educational sessions for the unit secretaries and directors to let them know that the Important Message was part of the admissions packet and what their responsibilities are for ensuring that the Centers for Medicare & Medicaid Services (CMS) requirements are followed.

"Because the letters have to be written according to CMS requirements, we were making copies of the copies each time the patient needed to have a new copy of the Important Message. Eventually, we ordered three-part paper forms, which work a lot better for us. We still have to make a copy if the patient stays beyond the intended discharge, but having the three-part forms has made it more efficient," she says.

Tracking delivery, compliance

The hospital set up a system so that once the Important Message is given to a patient, the information is entered into the electronic medical record so the case managers and access staff can see it without having to go into the chart.

The medical record contains the patient name, date of admission, and date the letter is due, allowing Reed to track the information on a daily basis. The case management staff review the daily reports. The access staff input the information into a spreadsheet every month to track compliance.

"Rather than having to go through all the Medicare charts, we set up a system so that the information was in the medical record and available to the case managers and access staff," she says.

The hospital assigned a temporary person on light duty who helps provide the notices, added an FTE utilization review specialist to the case management department to help with the process, and increased secretarial support for the department.

The medical center's hospitalist group manages a good portion of the medical patients and got involved with making sure patients were expecting their discharge from the beginning.

"Our physicians are doing a phenomenal job of talking with patients and involving them in the discharge," she says.

But some were so proactive in notifying patients of a pending discharge that the patients felt like they weren't ready to go home and chose to appeal.

"The physicians have gotten better in recognizing that we can't give out the Important Message letters too early," she said.

Reed and her committee have met with the hospital's compliance officer and are working on an action plan to improve compliance. "We still have growing pains and are not as compliant as we feel we should be," she says. The hospital is revising its discharge checklist to include the Important Message.

Identifying best practices

During the weekly team meeting, Reed goes over compliance with the Important Message floor by floor, pointing out areas where the compliance is higher, giving the team an opportunity to discuss the best practices.

"We look at whether the document was missed on admission or missed at discharge," she says.

For instance, if a patient is in the emergency department in a crisis situation, the staff are dealing with life or death issues and it would not be appropriate to read the patient their discharge rights, Reed points out.

Now, if the patient doesn't receive the notice on the first day, someone from the access staff goes to the floor and meets with the patient to discuss the document on the second day of the stay. The case manager provides the notice if the patient is slated for discharge before the access staff can meet with him or her.

"We're improving communication. The unit secretary goes over the list of who is anticipated to be discharged that day. If the patient is being discharged and there is a 'Red Alert' page in the chart, the secretary alerts the case manager," she says.

Facilitating the appeals process provided another challenge since the medical center is a 2½-hour drive from the Boston suburb of Waltham where the state's peer review organization (PRO) is located.

Reed and her team looked at setting up a courier service but decided it wouldn't be cost-effective because of the low volume of appeals vs. the cost for bonding a driver.

They ended up sending the appeals materials by overnight mail but, in some cases, it extends the stay for up to four days.

"If the discharge is planned for Friday, the patient has until midnight that day to appeal if they disagree with the plan. If we send it overnight, there's nobody to open the Saturday mail and the PRO has another 24 hours to respond after they see the chart," she points out.

Faxing the documents creates problems because the copies don't always go through clearly, she says.

Another delay occurred when the hospital sent the appeal by overnight mail but it didn't arrive until 1 p.m., and the PRO medical director wasn't available until the next day.

"We have to deal with family dynamics when a patient doesn't meet inpatient criteria but the family doesn't want him placed in a nursing home. There are also people who manipulate the system," Reed says. For instance, the daughter of one patient wasn't ready to take her mother home so she appealed. The PRO upheld the discharge but the woman gained a discharge delay.

"It's a real learning curve," Reed says.

Issuing HINNs

If the PRO notifies the patient that the hospital's decision has been upheld, the hospital can issue a Hospital Issued Notice of Noncoverage (HINN) notifying the patient that he or she is responsible for payment, effective on the next day or 24 hours after the decision is made.

"Keeping all of this straight has been a challenge. We have to keep going back and referencing which letters CMS says we should give out when," Reed says.

The new rules for notifying patients of their rights to appeal their discharge puts more emphasis on involving patients in discharge processes and preparing them to go home, Reed points out.

"As painful as it's been, it's helped place greater emphasis on the discharge process. It's not just the message. It's how we deliver the message. It's not effective to tell a patient they're going home today and surprise them. We should talk to patients about discharge throughout the day so they aren't surprised on the day of discharge," she says.