News & Analysis

April 1, 2016
Case Management Monthly

The number of drug overdoses related to opioids has more than quadrupled in the U.S. since 1999, according to the National Institute on Drug Abuse (NIDA). As of 2014, some 2.5 million Americans were thought to have a substance abuse disorder related to prescription opioid painkillers or heroin?and they're coming into hospitals where case managers are increasingly being called on to manage their care.

"The substance abuse epidemic seems exactly like that, an epidemic, with the numbers of patients suffering from substance abuse growing, with many presenting to the hospitals with serious overdoses and/or medical complications of their drug habits," says June Stark, RN, BSN, MEd, director of care coordination at St. Elizabeth's Medical Center-Steward Healthcare in Boston.

Scarce resources and the complex needs of these patients make helping patients with opioid addictions a challenge. Not only do case managers need to manage the challenges and social issues that go along with addiction, such as homelessness and lack of family connections, but they may also struggle to find placements for patients?there just aren't enough beds out there, Stark says, a possible side effect of years of cutbacks and reductions in these types of care options.

While in the past, many patients came into St. Elizabeth's Comprehensive Addictions Program suffering from alcohol dependence, today there's been a huge increase in individuals abusing prescriptions and other opiates, says Mary Ellen Peters, RN, BSN, CARN, a substance abuse case manager at St. Elizabeth's Medical Center in Boston. The growing number of opioid users and the increased publicity surrounding this issue has prompted more people to come in and seek help, she says.

In Massachusetts, you can't pick up a newspaper without hearing stories of struggles with addiction and the community's effort to get ahead of the crisis, says Peters. Even police departments are changing their approach, arming police officers and first responders with a lifesaving opioid overdose-reversal treatment, Narcan. The Gloucester (MA) Police Department is not only using Narcan, but has publicly changed its focus to trying to get people treatment, not jail time, says Peters.

While some changes are in the works that may help future case management efforts, today's case managers still face major challenges. Peters says they manage these challenges by taking a multi-pronged approach to address patient needs, consisting of:

  • A thorough assessment
  • Community referrals for follow-up care
  • Reaching out to family members for support
  • A focus on reversing social issues, which provide barriers to recovery
March 1, 2016
Case Management Monthly

Now that you've had time to recover from the first hectic months of the new year, it's time to focus on what the remainder of the year will bring for case management and some of the biggest challenges that may lie ahead in 2016.

 

  • Discharge planning Conditions of Participation changes. Ronald Hirsch, MD, FACP, CHCQM,vice president of the Regulations and Education Group at Accretive Health in Chicago, called CMS' proposed changes to the discharge planning Conditions of Participation (CoPs), which would revamp the discharge planning process, "the bombshell for 2016." 
  • BFFC-QIO audits. In October 2015, Quality Improvement Organizations (QIO) took over the role of education and enforcement for the 2-midnight rule from the Recovery Audit Contractors. In 2016, these Beneficiary and Family Centered Care QIO (BFCC-QIO) audits of short stays will be in full force, says Hirsch.
  • The new Comprehensive APC for observation patients. CMS approved a new comprehensive APC (C-APC) payment for observation patients for 2016, which provides payment for nonsurgical services provided to patients with an eight-hour or longer observation stay. Any ED-visit level code will qualify for the comprehensive APC code. "The new Comprehensive APC for observation patients means that hospitals need to be more efficient and avoid incidental testing which will no longer be paid," says Hirsch.
March 1, 2016
Case Management Monthly

The American Hospital Association asked CMS to clarify some aspects of its new outpatient notification requirement, Notice of Observation Treatment and Implication for Care Eligibility Act, which is supposed to go into effect in the summer of 2016.

March 1, 2016
Case Management Monthly

At the completion of this educational activity, the learner will be able to:

March 1, 2016
Case Management Monthly

Is your hospital in one of the 67 geographic areas defined by CMS as a metropolitan statistical area (MSA) and one that CMS has identified to participate in the Comprehensive Care for Joint Replacement (CJR) Model? If so, is your case management department ready? Does your department have the processes and procedures in place for how it will participate in this retrospective bundled payment innovative project for Medicare fee-for-service beneficiaries?

February 1, 2016
Case Management Monthly

On November 16, 2015, CMS released a final rule that bundles acute-care payments for knee and hip replacement surgeries, the most common type of inpatient surgeries for Medicare beneficiaries, with some 400,000 performed in 2004.

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