Access Point Case Managers: The Lynchpin for Hospital Admissions

Toni G. Cesta, Ph.D., RN, FAANPartner and Consultant

Case Management Concepts, LLCEast Coast Office

North Bellmore, New York

Bev Cunningham, MS, RNVice President ClinicalPerformance Improvement

Medical City Dallas HospitalAndPartner and ConsultantCase Management Concepts, LLCSouthern OfficeDallas, Texas

Tuesday, April 29th, 2014

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FACULTYToni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a     consulting company which assists institutions in designing, implementing and 

evaluating acute care and community case management models, new documentation systems, and other strategies for improving care and reducing cost. The author of eight books, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management. Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management. Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York. 

Bev Cunningham, RN, MS is Vice President, Resource Management at Medical City Dallas Hospital.  Her areas of responsibility include Case Management, Health Information Management, Clinical Documentation Integrity, Patient Access and Transplant Financial Services.  Bev is a well‐known speaker in the Case Management field.  Involved in the development of case management for over twenty five years, her areas of expertise include denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process.  She has served as a Commissioner on the Commission for Case Management Certification. Bev is also a partner and consultant in Case Management Concepts, a company that provides support to hospitals regarding effective Case Management model development and evaluation. Bev's publications include a chapter in CMSA's Core Curriculum for Case Management Certification and most recently, co‐author of the book, Core Skills for Hospital Case Management.   She is also on the advisory board for Hospital Case Management.

2

1. Discuss the role of access point case manager.2. Review how the role of access point case

manager can be implemented when considering all patients admitted to the hospital.

3. Explain new and revised case management standards, regulations, and laws put forth by CMS, TJC and the federal government.

4. Evaluate case management protocols and penalties.

LEARNING OBJECTIVES

EARLY CASE MANAGEMENT MODELS

DID NOT GIVE GREAT ATTENTION TO THE TWO FUNDAMENTAL ROUTES OF ENTRY TO THE HOSPITAL

ACUTE CARE SETTINGS NOW RECOGNIZE THE IMPORTANCE OF GATEKEEPING ACCESS POINTS

BY THE NUMBERS

IN 2008, 124.9 MILLION PEOPLE VISITED EMERGENCY ROOMS. OF THESE 113.3 MILLION CAME FROM PRIVATE RESIDENCES AND 3.45 MILLION FROM NURSING HOMES OR OTHER RESIDENCES

MORE THAN 9 IN 10 ED VISITS IN 2008 WERE RELATED TO ACUTE CONDITIONS, AND HALF OF THESE ALSO INVOLVED CHRONIC CONDITIONS. INJURIES COMPRISED 1 IN 4 ED VISITS.Agency for Healthcare Research and Quality

MORE BY THE NUMBERS

ED VISITS FOR PEOPLE BETWEEN AGES 65 AND 74 HAVE INCREASED THE MOST OVER THE LAST DECADE AND ARE PROJECTED TO NEARLY DOUBLE FROM 6.4 MILLION IN 2005 TO 11.7 MILLION BY 2013

Centers for Disease Control and Prevention

EVEN MORE

IN 2007, ABOUT 10% OF THE POPULATION UNDER AGE 65 VISITED THE ED FOR REASONS THAT WERE CONSIDERED NON-URGENT, DEFINED AS THOSE FOR WHICH THE PATIENT SHOULD BE SEEN WITHIN 2 HOURS TO 24 HRS OF ARRIVAL

Annals of Internal Medicine, 9/11/07

TOP TEN REASONS WHY YOU MUST HAVE ED CASE

MANAGEMENT1. Assignment of appropriate level of care from

the point of entry2. Manage the 2-Midnight Rule3. Recovery Audit Contractors (RAC)4. Reduction in readmissions5. Improvement of in-patient through-put6. Reduce the need to use Condition Code 447. Assure compliance with medical necessity8. Reduce commercial admission denials9. Manage observation service10. Increase patient satisfaction in the ED

THE NON-EMERGENCY IN THE EMERGENCY ROOM

INCREASING ED VISITS SUBSTANTIATED OVER LAST DECADE

MUCH OF THE INCREASE IS ATTRIBUTED TO THE USE OF EDs FOR NON-URGENT COMPLAINTS

BIG PUSH TO KEEP PATIENTS OUT OF THE HOSPITAL

A PROBLEM OF CARE DELIVERY TO THE POOR

WHAT DOES THE NON-EMERGENT PATIENT LOOK LIKE–LACK OF PHYSICIAN ACCESS–LACK OF PERSONAL PHYSICIAN–MEDICAID AS PAYER

THE NEW ED

IT IS AN ACCESS POINT IT IS ALSO AN EXIT POINT IF IT ISN’T AN EXIT POINT, YOU

REALLY DO NEED ED CASE MANAGEMENT

GOALS OF ACCESS POINT CASE MANAGEMENT

MANAGE AND CONTROL THE TYPES OF PATIENTS APPROVED FOR ADMISSION

PROVIDE FOR ALTERNATIVE CARE WHEN NEEDED AND APPROPRIATE

ENSURE HOSPITAL REIMBURSEMENT

ADMITTING DEPARTMENT CASE MANAGEMENT

PROVIDES GATEKEEPING FUNCTION FOR:–PLANNED ADMISSIONS–URGENT ADMISSIONS–DIRECT ADMISSIONS–TRANSFERS

ROLES AND FUNCTIONS

SCREENING OF POTENTIAL ADMISSIONS/TRANSFERS–USE CLINICAL INDICATORS–COMPARE PT’S SEVERITY OF ILLNESS

AND INTENSITY OF SERVICEAGAINST ESTABLISHED CRITERIA

ROLES AND FUNCTIONS

WHEN THE PATIENT’S NEEDS DO NOT MEET ADMISSION CRITERIA, THE PHYSICIAN IS CONTACTED

CARE ALTERNATIVES ARE DISCUSSED

ALTERNATIVE LEVELS OF CARE/SETTINGS

AMBULATORY SURGERYOBSERVATIONHOME CARESUB-ACUTE

LINK PATIENT NEEDS TO APPROPRIATE SETTING

NEVER DENY AN ADMISSION WITHOUT PROVIDING THE PHYSICIAN WITH ALTERNATIVE SETTINGS ALONG THE CONTINUUM THAT WOULD MORE APPROPRIATELY MEET THE PATIENT’S CLINICAL NEEDS AND ENSURE REIMBURSEMENT

SCREENING TRANSFERS

ENSURE THAT THE TRANSFER IS APPROPRIATE AND MEETS ALL MEDICARE GUIDELINES

AFTER ADMISSION APPROVAL

CASE MANAGER COMMUNICATES TO THE ADMITTING OFFICE

IF HOSPITAL HAS BED TRACKERS, THEY MAY ALSO NEED TO BE NOTIFIED

CM OBTAINS PRE-AUTH OR APPROVAL FROM INSURANCE COMPANY

REQUESTS FOR CLINICAL INFORMATION

IF INSURANCE COMPANY (THIRD PARTY PAYER) REQUESTS ADDITIONAL CLINICAL INFORMATION, THE CASE MANAGER MAY BE THE APPROPRIATE PERSON TO PROVIDE THE LINK BETWEEN THE CLINICIANS, ADMITTING DEPARTMENT AND INSURANCE COMPANY

SAME-DAY ADMISSIONS

REVIEW PRIOR TO DAY OF SURGERY TO ENSURE THAT PRE-AUTH HAS BEEN OBTAINED

PRE-ADMISSION TESTING

MEET AND “INTAKE” SELECT PATIENT GROUPS DURING PRE-ADMISSION PROCESS

IDENTIFY ANY PRE-ADMISSION ISSUES THAT MIGHT AFFECT THE IN-HOSPITAL STAY AND/OR DISCHARGE PLAN

EXPLORE DISCHARGE PLANNING OPTIONS WITH PATIENT/FAMILY

DISCUSS WITH ATTENDING PHYSICIAN WHEN POST-DISCHARGE NEEDS CAN BE CLEARLY IDENTIFIED

REFER TO SOCIAL WORKER/IN-PATIENT CASE MANAGER AS APPROPRIATE

ALL INTAKE INFORMATION SHOULD BE COMMUNICATED WITH THE IN-PATIENT CASE MANAGER SO THAT A SMOOTH TRANSITION CAN TAKE PLACE FROM THE PRE-ADMISSION TO IN-PATIENT SETTING

A PRE-ADMIT NOTE SHOULD BE PLACED IN THE MEDICAL RECORD

EMERGENCY DEPARTMENT CASE MANAGEMENT

ROLE FUNCTIONS:1. GATEKEEPER

SCREEN ALL ED PATIENTS FOR APPROPRIATENESS OF ADMISSION

OFFER ALTERNATIVE CARE SETTINGS INITIATE CONTACT WITH ADMITTING MD

(ED ATTENDING AND PMD) PROVIDE CLINICAL AND PAYOR INFO TO

MD

ROLE FUNCTIONS: 2. FACILITATE INITIATION OF CARE

1. ON TREAT AND RELEASE PATIENTS2. ON ADMITTED PATIENTS3. ON OBSERVATION PATIENTS

EXAMPLES OF INITIATION OF CARE

ADMINISTRATION OF MEDICATIONTESTS AND PROCEDURESCONSULTSOBTAIN RECORDS FROM OUTSIDE

OFFICES/INSTITUTIONSOFFER ED DISCHARGE PLAN (HOME

CARE SERVICES)

3. START INTAKE/UTILIZATION PROCESS

DATA COLLECTIONASSESS CURRENT LIVING

SITUATIONOBTAIN INFO REGARDING

INFORMAL AND FORMAL SUPPORTSLAB AND ANCILLARY TEST RESULTS INITIATION OF TREATMENTS

4. ENCOURAGE USE OF REIMBURSABLE DIAGNOSES

PNEUMONIA VS PNEUMONIA WITH RESP FAILURE REQUIRING MECHANICAL VENTILATION, SEPSIS

CHEST PAIN VS UNSTABLE ANGINA, R/O MI

ABDOMINAL PAIN VS GALL STONE PANCREATITIS

R/O SEPSIS VS CLINICAL SEPSIS

OTHER ROLES

INTERFACE WITH COMMUNITY AGENCIES

CREATE PLANS FOR HIGH UTILIZATION PATIENTS

REFER PATIENTS TO OTHER/MORE APPROPRIATE HOSPITAL AREAS

MONITOR AND MANAGE VARIANCES

COMMUNITY AGENCIES

HOME CARE AGENCIESSENIOR CITIZEN CENTERSDAY PROGRAMSPOLICE DEPARTMENTNURSING/ADULT HOMESPROTECTIVE SERVICES (CHILDREN

AND ADULTS)

START DISCHARGE PLANNING ON ADMITTED PATIENTS

SPEAK WITH AMBULANCE STAFF MEET WITH FAMILY/FRIENDS INTRODUCE IDEA OF HOME CARE OR

OTHER ALTERNATIVE SERVICES INTERFACE WITH IN-PATIENT CASE

MANAGERS CHECK THAT PATIENT HAS A PRIMARY

CARE PHYSICIAN THAT THEY ARE COMFORTABLE WITH

HIGH UTILIZATION PATIENTS

IN ED AT LEAST ONCE EVERY THREE MONTHS

MUST CREATE PLAN WITH ED STAFF AND PMD (IF PT HAS ONE)

DETOX/REHAB PROGRAMS, SNF, GROUP HOME

HELP OBTAIN MEDICATIONS WAIT THE SITUATION OUT

(ALZHEIMER’S) NO MEALS/SHOWERS/CLOTHES/MONEY CONSISTENT APPROACH

OTHER HOSPITAL AREAS

DIRECT ADMISSIONAMBULATORY SURGERYCANCER CENTERELECTIVE PROCEDURES

(ENDOSCOPY)OTHER SPECIALTY AREAS

REFERRALS- FINDING PATIENTS

TRIAGE NURSE – EMS, POLICESTAFF – RN, MD, SW, PMD, CLERKS IN-PATIENT CASE MANAGERSFAMILY, FRIENDS, NEIGHBORS OF

THE PATIENTCOMMUNITY AGENCIES

INTEGRATING CM AND SOCIAL WORK: SHARED RESPONSIBILITIES

REFERRALS TO HOME CAREREFERRALS FOR DETOXTRANSPORTATION ISSUES OF NONCOMPLIANCE

INTEGRATING CM AND SOCIAL WORK:ISSUES OF NON-COMPLIANCE

CASE MANAGEMENT PT EDUCATION;

ASSESS FOR KNOWLEDGE DEFICIT, MEDS, FOLLOW-UP APPTS

SOCIAL WORK REFUSAL TO ACCEPT

NEEDED SERVICES LEAVING AGAINST

MEDICAL ADVISE CRISIS

INTERVENTION: SUBSTANCE ABUSE, FAMILY DYSFUNCTION, COPING WITH ILLNESS

INTEGRATING CM AND SOCIAL WORK: ISSUES OF PAYMENT

CASE MANAGEMENT QUESTIONS ABOUT

INSURANCE COVERAGE

SOCIAL WORK ENTITLEMENTS(MEDICAID,

DISABILITY, AIDS SERVICES, FOOD STAMPS)

COMMUNITY SERVICES (HOUSING, RED CROSS)

INTEGRATING CM AND SOCIAL WORK: OBTAINING MEDICATIONS

CASE MANAGEMENT ASK MD TO

PRESCRIBE LEAST COSTLY DRUG

ASK HOSPITAL PHARMACY TO GIVE MEDS

VOUCHER SYSTEM WITH LOCAL PHARMACY

SOCIAL WORK REFER FOR

ENTITLEMENTS HELP PT NEGOTIATE

PAYMENT PLAN WITH LOCAL PHARMACY

EXPLORE OTHER OPTIONS (VA HOSPITAL)

VOUCHER SYSTEM WITH LOCAL PHARMACY (SHARED FUNCTION)

INTEGRATING CM AND SOCIAL WORK:HOMELESS PATIENTS

CASE MANAGEMENT SHELTER REFERRALS

SOCIAL WORK SOCIAL HISTORY FINANCES CONTACT

FAMILY/FRIENDS COMMUNITY

AGENCIES

PURE SOCIAL WORK ISSUES

ISSUES OF CHILD ABUSE AND NEGLECT ISSUES OF DOMESTIC VIOLENCE, ELDER

ABUSE, SEXUAL ASSAULT, INSTITUTIONAL ABUSE

COUNSELING IN RESPONSE TO DEATH, TRAUMA, ACCIDENTS, INJURIES

CRISIS INTERVENTION LEGAL CONCERNS (GUARDIANSHIP)

CASELOADS AND COVERAGE HOURS

AT A MINIMUM COVER PEAK VOLUME TIMES IN THE ED

CONSIDER STAGGERING THE HOURS OF THE SOCIAL WORKER AND NURSE CASE MANAGER FOR MAXIMUM COVERAGE

NUMBER OF STAFF WILL DEPEND ON THE:– ED VOLUME– PAYER MIX– ADMISSION VOLUME

MEASURING SUCCESS

DECREASE IN COMMERCIAL ADMISSION DENIALS ND RAC DENIALS RELATED TO 2 MIDNIGHT RULE

REDUCTION IN READMISSIONS DECREASE IN ED LOS IMPROVED PATIENT SATISFACTION IMPROVED PHYSICIAN SATISFACTION DECREASE IN NUMBER OF ‘HIGH

UTILIZATION’ PATIENT VISITS DECREASE IN INPATIENT LOS

REDUCE ADMISSION DENIALS

COORDINATE 2 MIDNIGHT RULE PROCESS ASSURE MEDICAL NECESSITY ON NON

MEDICARE PATIENTS PROMOTE ACCURATE DOCUMENTATION DISCUSS TREATMENT AND DISCHARGE

PLAN WITH MD CONDUCT PHYSICIAN EDCUATION

INCLUDING COMMUNITY RESOURCES AND OTHER OPTIONS

REDUCTION IN READMISSIONS

REVIEW PATIENTS IN ED WHO HAVE BEEN DISCHARGED WITHIN 30 DAYS OR LESS

CONSIDER ALTERNATIVES TO READMISSION WITH THE PHYSICIAN

WATCH FOR PATTERNS BY:–ADMIT SOURCE–MD

DECREASE IN INPATIENT LENGTH OF STAY

EARLY INTERVENTION = QUICKER PROGRESSION OF CARE = EARLY DISCHARGE

MAKE THE BEST USE OF THE TIME THE PATIENT SPENDS IN THE ED

TESTS ORDERED FROM THE ED ARE OFTEN GIVEN PRIORITY OVER THOSE ORDERED FROM AN IN-PATIENT UNIT

IMPROVE PATIENT SATISFACTION

KEEP THE PATIENT INFORMEDEXPEDITE TESTS AND PROCEDURES INFORMATION GATHERING BY THE

ED CM IS OFTEN PERCEIVED AS ‘CARING’ BY THE PATIENT/FAMILY

IMPROVE PHYSICIAN SATISFACTION

NOTIFY THE PRIMARY CARE PROVIDER THAT THEIR PATIENT IS IN THE ED

RE-NOTIFY THEM IF THE PATIENT IS ADMITTED

GATHER RELEVANT HISTORY ON THE PATIENT

DECREASE LENGTH OF STAY IN THE ED

ANTICIPATE ED DISCHARGESMEET PATIENT’S FAMILY, FRIENDS

OR CAREGIVERS EARLY IN ED STAY IDENTIFY AND COMMUNICATE WITH

COMMUNITY RESOURCES IN PLACE AND/OR AVAILABLE TO THE PATIENT

MAKE SOCIAL WORK REFERRALS

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relationship with the presenter(s). You should not take any action based upon any information in this presentation without first consulting legal 

counsel familiar with your particular circumstances.

THANKS!

PLEASE FEEL FREE TO CONTACT US AT:

cestacon@aol.com

bevcmc@hotmail.com