Hospital case management : the monthly update on hospital-based care planning and critical paths
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The Centers for Medicare & Medicaid Services has declared that stays that span two midnights should be presumed to be inpatient stays, but case managers still need to make sure patients meet inpatient criteria and that the documentation is complete. Physicians must certify medical necessity, sign, date, and time the admission, and include a treatment plan and the anticipated length of stay. Physician documentation must be accurate, detailed and give a complete picture of what's going on with the patient or hospitals could face significant payment implications. Medicare auditors still will be scrutinizing the records and are likely to continue to target one-day stays and two-day stays for medical necessity.
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In the Inpatient Prospective Payment System proposed rule for fiscal 2014, the Centers for Medicare & Medicaid Services (CMS) has proposed changes to how auditors review inpatient admission and announced plans for basing reimbursement on additional quality measures. CMS proposes that auditors should presume that inpatient status is appropriate if there is a physician order and the stay spans two midnights. The agency proposes penalizing hospitals for excess hospital-acquired conditions, adding chronic obstructive pulmonary disease and total hip and knee replacements to the readmission reduction program, and announced that it is considering adding a measure to value-based purchasing in fiscal 2017 that assesses a hospital's performance in treating Medicare patients appropriately as inpatients or outpatients. The Recovery Auditors and other Medicare contractors will continue to scrutinize medical records and are likely to shift their emphasis to 0-to-3-day stays.
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Sycamore Medical Center's Lean project to improve patient flow in the emergency department resulted in an increase in patient satisfaction scores and a decrease in patients who left without being seen. A multidisciplinary team analyzed how patients arrive, how they are treated, and how they are triaged. The team examined the work of all emergency department staff and made changes to optimize their time. The team created a set of essential care orders the hospital can use if the patient is stable and can go to the floor.
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Bassett Medical Center's readmission project cut 30-day readmissions by up to 70% for the highest-risk patients and resulted in the medical center being one of only 20 hospitals in New York State that did not incur readmission penalties from the Centers for Medicare & Medicaid Services. The care coordination team includes case managers, social workers, and patient service coordinators who set up post-acute services and call at-risk patients within a day of their discharge. Case managers round with physicians and refer patients who have psychosocial needs to the social workers for follow up. Continuing care coordinators at primary care offices attend multidisciplinary rounds with the hospital team and receive detailed information about the hospital stay.