Each year, some 400,000 patients in the U.S. receive home parenteral and enteral nutrition (HPEN), and that number is expected to grow as the population ages, the malnutrition epidemic becomes greater, and the push to improve nutrition to improve patient outcomes increases, says Noreen Luszcz, MBA, RD, CNSC,the national nutrition program director for Option Care, a home infusion provider for adult and pediatric patients.
The right physician advisor can be an ally for case managers, helping to improve communication and cooperation with physicians, bolstering compliance efforts, and helping to avoid delays in care that can keep patients from moving seamlessly through the system.
The readmission rate is dropping, but are hospitals just doing a quick shuffle--shifting patients from inpatient status to observation services--to make that change happen?
The study "Readmissions, Observation, and the Hospital Readmissions Reduction Program" published in the February 24 issue of the New England Journal of Medicine says that is not the case. The decline in readmissions is real, says the study, and likely in response to the Hospital Readmissions Reduction Program (HRRP), which fines hospitals for excessive readmissions.
CMS implemented the HRRP in 2010 in an effort to save the government money on the $17 million in estimated avoidable costs incurred each year from unnecessary hospital readmissions and to spare patients the poor outcomes that send them back to the hospital after they are discharged home.
The readmission rate has declined since the implementation of HRRP. But at the same time, some pointed to the fact that use of observation services was increasing and wondered if the two were connected. Others questioned whether the HRRP was actually making a difference in readmission rates, which were already on the decline before the program went into place.
The findings of this study validate what some case managers say they knew all along.
"Personally, as a director of case management I have never seen observation status used to avoid the readmission penalty," says June Stark, RN, BSN, MEd, director of care coordination at St. Elizabeth's Medical Center, Steward Healthcare in Boston.
Documentation can be a headache for everyone, from the physicians who have to take precious time away from patients to document in the EHR to the case managers who have to track the physicians down to fill in gaps when information is missing from the medical record.
The case manager plays a crucial role in helping to make sure medical record documentation not only supports billing and coding to ensure accurate reimbursement, but also clearly communicates the patient's condition to the entire clinical team.
It needs to be complete, accurate, succinct, and effective, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, PCS, FCS, CPUR, C-CDI, CCDS, director of enterprise solutions at Zirmed. However, it's often anything but. Krauss says he often comes across documentation that case managers could help clarify, and he recently offered some real-life examples (with details changed to protect patient privacy) to illustrate key points.
Case managers can help resolve common problems found in patient charts, including insufficient clinical information and missing basic information.
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
Research shows that ethnic and racial minorities may wind up back in the hospital after discharge more often than their white counterparts for certain conditions, such as pneumonia and heart failure. This increased rate of readmissions is due to many factors, including:
A higher incidence of some chronic diseases
Social, economic, cultural, and linguistic barriers to care
CMS is hoping to change that with a new publication, "Guide to Preventing Readmissions Among Racially and Ethnically Diverse Beneficiaries." Its authors said that the guide aims to accomplish three main goals:
Providing an overview of the issues that can lead to higher readmission rates among this group
Outlining actions hospital leaders can take to reduce these avoidable readmissions
Providing case studies and examples of initiatives that have worked to reduce readmissions among racial and ethnically diverse Medicare beneficiaries
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.
