Hospital case management : the monthly update on hospital-based care planning and critical paths
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It's no longer a luxury for hospitals to have case managers in their emergency departments, according to some case management experts--it's a necessity to make sure patients are admitted in the proper status and to ensure that those being discharged from the emergency department have what they need to manage their conditions. Hospitals need to ensure that patients meet medical necessity criteria to avoid losing reimbursement. Case managers can help provide a smooth transition from the emergency department back to the community and connect patients with post-discharge services. Case managers can work with patients who frequently utilize the emergency department and educate them about more appropriate venues of care.
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Medicaid recipients in a pilot project at MetroHealth Medical Center in Cleveland, OH, reduced their emergency department visits significantly. Working with primary care physicians, the hospital staff drew up care plans for each patient and entered them into the medical record so they would be available to the emergency department staff. Participating Medicaid Managed Care Plans embedded case managers in primary care offices to educate the patients on appropriate use of the emergency department. The pilot has ended but the hospital and managed care plans continue to collaborate on managing patient care.
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The Centers for Medicare & Medicaid Services' proposed rule for the Inpatient Prospective Payment System strengthens ties between Medicare reimbursement and quality improvement. The proposed rule expands Hospital Inpatient Quality Reporting and Value-based Purchasing. Shift to payment for quality makes it essential for documentation to be accurate and complete. To ensure optimal reimbursement, hospitals must manage care transitions and take steps to avoid hospital-acquired conditions.
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Auditors from all types of payers are focusing their attention on patients'level of care making it imperative for hospitals to ensure that the level of care is appropriate and the documentation supports it. There are a lot of grey areas in the rules and admission criteria sets and the Recovery Audit Contractors (RACs) are looking at them as tools, and not as definitive answers as to whether patients meet inpatient criteria. ⋯ Patients appropriate for observation services are those who need additional care or who need to be reassessed before a decision on admission is made. At some hospitals, case managers on the surgical unit conduct reviews to ensure that patients are placed in the proper status after surgery.