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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Two-thirds of hospitals in the United States are losing reimbursement on each Medicare discharge as a result of their performance on the Centers for Medicare & Medicaid readmission reduction program--and the penalties and diagnoses included will only escalate. Hospitals and case managers have to make a paradigm change and focus not only on moving patients through the continuum but keeping them from returning to the hospital, some experts say. Reach out to post-acute providers and make sure that they have the information they need to care for patients at the next level of care and that patients aren't receiving follow-up calls from multiple sources. Analyze all readmissions to determine why patients came back and take steps to improve your processes.