HCPro.com - Case Management Monthly

Is certification right for you? Factors to consider when making this decision

Sun, 01 Jul 2012 04:00:00 GMT

Is certification right for you? Factors to consider when making this decision

After reading this article, you will be able to:

Identify the advantages and disadvantages of seeking professional case management certification
Determine which type of certification might be beneficial

Just a few years ago, few employers required certification for new case managers. Today, more than one-third seek this stamp of approval when they bring someone new on board.

The Commission for Case Management Certification® (CCMC) reports on its website that 36% of employers required case managers to be board certified in 2009, a 10% increase since 2004.

The number of case managers seeking certification is also on the upswing. For example, more than 30,000 case managers have achieved Certified Case Manager® (CCM) certification, which is only one type of certification open to the profession, according to the CCMC website. The Case Management Society of America (CMSA) lists more than 20 organizations that offer different types of certification to case managers on its website.

But is certification right for you?

Experts say that certification has both advantages and disadvantages. Deciding whether to seek certification is the first step. Case managers must then decide which type of certification to seek.

So where do you start? The first step is to weigh the advantages of certification against its drawbacks.

Certification brings rewards

The primary advantage of certification is that it offers a greater sense of professionalism. This is true both for individuals and their employers, says Sandra Lowery, RN, BSN, CCM, CRRN, CNLCP, a senior consultant and trainer at CCMI Associates in Francestown, N.H.

It also demonstrates additional skill.

"Licensure means [a case manager] has met the minimum requirements in his or her field," says Jackie Birmingham, RN, MS, CMAC, BSN, vice president emeritus of clinical leadership at Curaspan Health Group in Newton, Mass. "Certification shows knowledge and experience above what is required for licensure."

Certification also demonstrates initiative.

"Certification is the mark of a person who is committed to their professional development and, especially if it is not a requirement for hire, definitely shows initiative and interest in being a lifelong learner," says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of The Center for Case Management, Inc., in Wellesley, Mass.

It may also increase confidence level and self-esteem related to one's ability to do the job, says Lowery.

Certification can bring other more tangible benefits. It can boost salaries and help case managers climb the career ladder within their organizations, says Lowery. CCMC reports that 27% of employers offered additional dollars to certified case managers in 2009 compared to 20% in 2004.

"It may also open the door to a management position," says Lowery. "It's very difficult now for case managers to move into a supervisory position without certification."

Some case managers no longer have a choice about seeking certification. "Approximately one-third of those who take the CCM exam today are doing so because their employer requires certification," says Lowery. This certification requirement applies to both new hires and to case managers who want to retain an existing position.

Many experts say case managers are wise to choose certification. "I strongly recommend case managers to become certified. It shows professional commitment and value. Just like nurses or social workers specialize, case managers need to show they have unique knowledge and skills that set them apart," says Birmingham.

Be prepared to commit time and money

There is really no downside to studying for certification and taking the test, says Zander. However, case managers should consider the costs and risks associated with certification, says Lowery.

Some employers help their employees pay for certification, but this is an out-of-pocket expense for many case managers. Some employers don't place any value on certification.

"I heard of a case manager last week who is pursuing certification despite the fact that her manager had never even heard of certification," says Lowery. Employees of organizations that share this perspective must pay registration fees, which could increase if they fail and need to repeat the exam.

Continuing education to maintain a credential can be expensive and include hidden costs, such as travel expenses and time away from work, says Birmingham. Incurring costs associated with certification without a boost in salary or position makes the effort financially unprofitable in some cases.

Also consider whether you have time to prepare for the examination, a process that takes anywhere from two weeks to six months, depending on the individual, says Lowery. This can be a considerable burden for individuals balancing a job and family responsibilities, she says.

Once you receive certification, you must maintain it with continuing education, says Birmingham. Certification typically expires in five years. "Too many folks wait until year four to start getting the required continuing education credits," Birmingham says. Certifying organizations typically require that individuals either complete a certain number of continuing education units/credits or take an exam to be recertified. Studying for the test is often more difficult than obtaining education, says Birmingham.

Another downside is the risk of failure and the subsequent blow to self-esteem. Only 70% of CCM test-takers pass the first time, according to the CCMC website. Failure can affect your self-confidence and lead you to question your ability to do the job.

Assess value and importance of certification

Some case managers also question how relevant certification is to the actual job of a case manager. Lowery says some test-takers have told her that some certification tests don't include information relevant to a case manager's day-to-day job activities.

Another consideration is whether organizations overemphasize the importance of certification, says Zander.

"People and organizations can lose perspective on the importance of certification," she says. "I don't think that hiring someone who is certified necessarily means that they can do the role that they are hired for. In other words, there is no guarantee for either the case manager or the organization that they have the competency for the job."

Certification tests focus solely on knowledge-not application or values, says Zander.

"Interpersonal skills, communication skills, and the ability to work on a team are equally important," says Birmingham. Certification should only be one consideration when making hiring decisions for this reason, she says.

Deciding which certification is best for you

Despite criticism, certification seems here to stay. If you decide to seek certification, you must decide which one is right for you.

Employers most likely will want certification in case management or a clinical specialty related to your assigned patient population, says Birmingham.

Employers can be providers such as hospitals, nursing homes, home health organizations, inpatient rehabilitation facilities, long-term acute care hospitals or hospice organizations, so an employer should consider both the case management skills and the clinical skills needed for those case managers who work with patients, Birmingham. says "Other employers are payers, and they need case managers with certification in utilization management. Some need clinical certification if they work in a disease management program or a complex case management program, for example." Certification is not one size fits all. Review the job description and match certification with an employer's expectations.

Most case management publications include a list of certifications and their eligibility requirements in at least some of their issues that can serve as a reference, says Zander.

"My advice to case managers planning on taking a test would be to pick the one that best matches either your current situation or stretch a little and take one that shows you have more advanced or generalized knowledge," she says.

Once you find a certification that seems like a good fit, ensure that the organization is reputable and respected in your industry. Lowery says your answer to all of the following questions should be yes:

Is certification research-based? Certification criteria should rely on major and extensive research into the role and function of a case manager in the field. If not, consider looking elsewhere.
Is it a pass/fail exam? Without a pass/fail exam, demonstrating specific skills, which is important, is difficult.
Does it require job experience? Some certifications allow candidates to take the exam without demonstrating experience, which is not ideal.
Do employers recognize the particular certification? This is an important consideration. Don't seek certification that hiring managers don't recognize.

However, don't let facts get in the way of your decision-making, says Birmingham. "Take the [certification exam] you think you can pass, and the one you're interested in," she says. "It's not just an exercise for your job, it's also for yourself."

Editor's note: Access information about CCMC at http://ccmcertification.org.

Access additional certification information from CMSA at www.cmsa.org/Individual/Education/AccreditationCertification/Certification/tabid/261/Default.aspx.

Preparation strategies for certification exam success

Explain how to successfully prepare for a certification examination
Use strategies that will help you pass the test on your first attempt

Preparing for a certification exam? These tips can help you pass the first time.

Sandra Lowery, RN, BSN, CCM, CRRN, CNLCP, a senior consultant and trainer at CCMI Associates in Francestown, N.H., helps case managers prepare for the Certified Case Manager® (CCM) test administered by the Commission for Case Management Certification® (CCMC), which is a separate organization. Her initial advice is to stay mum about plans to take the test. Telling friends and coworkers adds pressure that can make failure feel that much worse.

Now, it's time to study. Look for online resources. When preparing for an examination, look to the sponsoring organization for information about the test. Check the organization's website for more information, and call the sponsor if you have questions, says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of The Center for Case Management, Inc., in Wellesley, Mass. For example, if you plan to take the CCM exam, the CCMC website offers a number of tools that you can use to prepare, such as practice exams, webinars, and tools.

Other non-affiliated resources such as flash cards, sample questions, and books can help you prepare for the test, says Lowery.

You'll also have a choice of textbooks and study guides, says Dia Moore, RN, CCM, C-CDI, senior vice president of clinical services at AAACEUs.com®, which provides continuing education for case managers and other certified health professionals.

"I think the study guides are better because they are more succinct. Guides that include test questions are particularly good for people who haven't taken a test recently or have test anxiety," she says.

Buyer beware. If you decide to use a test preparation service, beware of the hard sell, says Moore. Conduct your own research to determine whether a company's products or services are a good match for your needs. Don't be coerced into purchasing something that might not suit your needs or learning style. If you purchase study aids, be certain that they are current and not out of date, she says.

Focus on your weak areas. Select study materials that fill in your knowledge gaps. For example, if you've worked as a case manager in only one clinical setting, consider study aids that focus on unfamiliar practice areas. If you've worked in different settings, focus on what you consider your weakest area.

The exam will probably be most challenging for case managers who have worked in only one setting, says Lowery. "The more experience [case managers] have in the various settings, the bigger advantage they will have in terms of a knowledge base," she says.

Joining forces with colleagues who will take the same certification test can improve your performance, particularly if they have different practice backgrounds and can help fill in your gaps, says Moore.

Know yourself. Tailor your study methods to your learning style, says Lowery. If you learn best by taking sample exam questions, follow that route. If you learn best with written information, read a book.

"Take any sample tests that are offered. Attend a prep course if offered," says Zander. Read study references recommended by the certifying agencies to assess your familiarity with information likely to be tested.

Practice exams can be particularly useful if you find test-taking stressful. Completing practice exams is the best way to squelch anxiety, says Moore.

Seek colleagues' perspectives. Before an exam, speak with colleagues who have already passed it for an overview of the experience. Tests change over time, says Moore, but much of the core information remains. Ask which topics should be your focus when studying, she says.

Understand complex concepts. Study concepts that are a focus of the test you plan to take. For example, study ethical practice in case management, the psychosocial effects of injury and illness, and outcomes by practice setting to prepare for the CCM© exam, says Lowery. Remember that this particular exam doesn't emphasize any particular clinical area, and that it includes behavioral health, she says. Sharpening your focus can help you make better use of your preparation time, Lowery says.

Think, don't just memorize. Some certification tests require you to think rather than rely on rote memorization. "The CCM© is not an exam only for memorization of information," says Lowery. "They clearly want you to be able to use your critical thinking skills and deductive reasoning skills, in addition to having knowledge." Be certain that you know the information and how to apply it.

Employ good study habits. The best strategy for success is to study intensely closer to the exam day. Ideally, your heavy study period should be three weeks to a month before a test, says Moore. This helps ensure that information is fresh in your mind and easy to retrieve during your exam.

Know the test. Not all test questions will count on every test. For example, some of the questions on the CCM© exam are for research purposes and don't count toward the final score, says Lowery. Knowing this can help reduce the pressure many test-takers experience, she says.

Don't cram. Staying up late studying the night before a test won't boost your performance, and might actually hinder it, says Moore. Also focus on eating well before the exam to boost your performance. This is not the time to consume just coffee and eat sugary doughnuts.

Don't dwell on your answers. When you take any standardized test, it's best not to dwell on your answers and be cautious about going back and making changes. Typically you'll do best if you go with your first impulse and move on, says Moore. Another effective strategy is ruling out answers that are definitely wrong. This improves your odds of answering correctly, she says.

Pay attention to detail. Your test-taking experience won't be very successful if you miss the test due to a registration error. The CCM© exam is administered in April, August, and December, according to the CCMC website. Candidates must register for the test three months beforehand; this catches some individuals by surprise, says Lowery. Take time to understand certification requirements so you don't miss an opportunity.

Before you send a check, be certain you meet exam eligibility requirements, says Moore. If you don't take the time to find that out first, you could be wasting your money, she says. Always be certain to call a certification organization if you're uncertain whether you qualify.

Stay positive. If, in the end, your studying doesn't pay off and you fail the certification exam, it doesn't mean that you're not a good case manager. "There is a certain skill to taking exams. There are some excellent case managers who have failed this exam," says Lowery. Sometimes it's your test-taking skills, not your knowledge that's the problem. And if you suspect that your test-taking abilities caused you to fail, take time to review test-taking strategies before your next attempt. An Internet search can yield useful tools to help you improve in this area.

An average of 30% of first-time CCM© test-takers fail the exam, according to the CCMC website. If you're among them, you can always try again.

Develop strategies to engage case managers in the document review process

Sun, 01 Jul 2012 04:00:00 GMT

Better chart scrutiny improves documentation

Explain the benefit of more detailed patient chart assessment by case managers
Develop strategies to engage case managers in the document review process

If you merely review patient charts and compare them to screening criteria, such as InterQual® or Milliman®, you’re not doing enough.

Sometimes what’s missing is more important than the details included in a chart, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, CCDS, an independent health information management consultant in Madison, Wis.

Case managers need to review charts with a clinical eye to ensure that physician notes accurately reflect the severity of a patient’s condition. Doing so helps an organization document medical necessity for billing purposes and helps case managers do their jobs more effectively by providing a more accurate assessment of patient condition, says Cindy Compton, CCS, C-CDI, CDIP, FCS. Compton is director of social services at Jane Todd Crawford Hospital in Greensburg, Ky., and Casey County Hospital in Liberty, Ky.

Look for details

When reviewing a patient chart, case managers should determine whether the notes accurately document a patient’s condition. For example, a chart might indicate that a patient presented with chest pains, but does the chart include additional signs and symptoms? Does it indicate that the physician thinks the signs and symptoms may indicate a more serious condition, such as possible heart attack, pulmonary embolism, or abdominal aortic aneurysm? If this information is missing, billing issues can occur down the road, says Krauss.

The Novitas Solutions Documentation Worksheet is useful when case managers assess patient charts. Case managers can use this form to determine whether gaps that highlight a need from more information from a physician exist, says Krauss. Access the worksheet at www.novitas-solutions.com/em/pdf/scoresheets/8985.pdf.

Case managers should improve communication with physicians, says Krauss. Instead of sending a physician a note with a generic statement that information is missing from a chart, be specific. Provide detailed information about what information is needed so the chart more accurately documents the severity of a patient’s condition. Create a laminated tip sheet with the documentation worksheet to help ensure that physicians don’t omit important information, Krauss advises.

Physicians generally already know this information and use it to manage a patient, but fail to clearly document it in the record. Case managers should guide physicians to capture and accurately report patients’ true severity of illness.

Use the “sample documentation clarification request” on p. 7 to elicit information that is missing from a patient’s medical record.

Team up with CDI

Joining forces with clinical documentation improvement (CDI) staff is another way for case managers to acquire the skills they need to perform more detailed chart reviews. Ideally, CDI staff should provide this training to case managers so they have the necessary knowledge to better assess patient charts at the outset, says Compton.

Ideally, case managers should undergo a formal documentation program, says Compton. “This gives them a foundation and then they can come back to their facility and tailor the information,” she says.

Case managers don’t need to become experts, they just need to understand the issue well enough to identify problems, she says.

Case managers already have an advantage in this area because they’re usually nurses and are attuned to disease processes, she adds.

Focus on documentation early

Case managers should begin working with patients to develop a discharge plan upon arrival at a facility. Ideally, they also should begin reviewing patient charts at the outset of work with physicians to ensure keywords are documented, says Compton.

“A lot of times physicians won’t want to commit themselves to a diagnosis, but will spread signs and symptoms throughout the chart,” she says. Case managers must help them focus that information.

Physicians who document signs and symptoms should also include an associated clinical condition or disease process that they are working up while managing their patients, says Krauss.

Assess documentation at your facility

Begin assessment of charts at your facility by reviewing a recent sample of one- and two-day inpatient stays, says Krauss. Target symptom codes that often attract scrutiny, such as the following:

Heart failure
Back pain
Chest pain
Pelvic pain

Review charts to determine whether the written record reflects patient acuity.

Ask yourself the following questions:

Do you see the severity of signs and symptoms exhibited by the patient?
Do you get a good picture of severity after reading the patient’s chart?

Remember that Medicare reserves the right to deny claims even if they meet commercially available screening criteria. “The record needs to speak for itself,” says Krauss. And case managers should be doing their part to ensure that it does.

Sample documentation clarification request?

ABC Medical CenterDocumentation Clarification RequestNo.Category: Clinical Documentation Improvement ProcedureNo.Title: Clinical Documentation Clarification RequestNo.Current revisionCurrent revisionOriginal effectivePage x of yDate: xx/xx/xxN/ADate: xx/xx/xx

Date: _________________________________?

Dear Dr. ______________________________:?

A review of the record of [patient identification number] identifies the need for additional clarification due to one (or more) of the following circumstances [circle all that apply]:

a) Clinical indicators of a diagnosis but no documentation of the condition

b) Clinical evidence for a higher degree of specificity or severity

c) A cause-and-effect relationship between two conditions or organisms

d) An underlying cause when admitted with symptoms

e) Only the treatment is documented (without a diagnosis documented)

f) Present-on-admission (POA) indicator status

Please provide the requested clarification in the progress notes and/or discharge summary.

[Insert request here. Include clinical indicators.]

Thank you for your assistance.

Respectfully submitted,

________________________________________

[Name of CDS reviewer]

_______________________________________

[Contact information (telephone/email)]

Source: Adapted from The Clinical Documentation Specialist’s Handbook, published by HCPro, Inc.

Case Management Monthly, July 2012

Sun, 01 Jul 2012 04:00:00 GMT

Ensure the right fit when hiring a physician advisor

Fri, 01 Jun 2012 04:00:00 GMT

Ensure the right fit when hiring a physician advisor

After reading this article, you will be able to:

Identify the qualities an individual needs to be a strong physician advisor (PA)
Develop strategies for assessing PA performance, providing training, and learning when it's time to sever a PA relationship

Your physician advisor (PA) provides a critical link between case management and physicians. It's a job that requires deft communication skills, regulatory know-how, and a stiff backbone.

Not all physicians are cut out to be PAs, says Linda Sallee, MS, RN, CMAC, ACM, IQCI, director of Huron Healthcare in Chicago. And many physicians don't actually want the job, she says.

It's a challenging role that sometimes pits PAs against their colleagues. "The PA is often in a position to have to take unpopular stands with the medical staff, which can become a real challenge, particularly if they have to push a colleague that might be a referral source," says Mark Michelman, MD, MBA. Michelman serves as medical director of case management and vice president of medical affairs at Morton Plant Mease Health Care in Clearwater, Fla.

For case managers, getting the right person for the job can pay big dividends-shorter LOS, fewer denials, and more appropriate use of medical tests.

It takes skill to find a good match. The following strategies can help you hire the right PA, improve existing PAs' skills, and know when it's time to replace a PA who isn't working out.

Hiring a strong advisor

The best way to ensure you have a strong physician advisor is to hire carefully, says Sallee.

Michelman suggests looking for candidates with the following skills and experience:

Has been a member of the medical staff for several years
Is familiar with "untouchable physicians" who bring great value, but can be difficult to manage
Enjoys the respect of colleagues and is viewed as credible by them
Can commit the necessary time to the role
Is willing to confront colleagues when necessary

Personality is among the most important characteristics a PA brings to the position, says Sallee. You can train physicians with respect to standards and regulations, and you can teach them what to look for, but a PA who can't communicate effectively and follow through with fellow physicians won't be a good fit, she says.

Determine whether someone would be a good hire by posing real-life scenarios. Ask how candidates would respond in particular situations to gain insight into personality and management style. Be clear when discussing the job's challenges with candidates, says Sallee. The person you hire should have realistic expectations; otherwise problems could occur later.

Don't rule out a physician based on medical specialty. Case managers debate about what type of physicians make the best PAs. Many successful PAs have internal medicine and family practice backgrounds, but consider other specialties as well, says Sallee, adding that the right temperament is more important than a physician's specialty.

Some organizations retain retired physicians to serve as PAs. This has advantages and disadvantages. A retired physician isn't beholden to anyone for referrals, but might not be as up to date as a working physician, says Michelman.

Looking for PA candidates on the job

Hiring a PA isn't an easy process. There is often a dearth of willing candidates for this unpopular position, says Michelman. With this in mind, case managers should always be trolling for good recruits. Look for physicians who are credible and seem to be moving up the chain of leadership. Also look for those with legible handwriting and good admission status. Focus on physicians who follow rules and regulations. You want a physician who consistently has appropriate LOS, not someone known for overutilizing medical tests. If you see someone who fits the criteria, consider recruiting that individual for the position.

If you can't find an appropriate internal candidate, consider hiring an external organization to perform the service, says Michelman. These external arrangements are generally effective, but often more costly than an in-house program.

Helping your PA improve

If you already have a PA, remember the importance of regularly assessing job performance. The first step is ensuring that you clearly define goals and expectations for your PA. You can't measure outcomes if you don't have established targets, says Michelman. These goals should be concrete and easy to measure. For example, ask the PA to reduce the number of avoidable days in the hospital stay and the number of discharge delays, he says. Other potential goals might be reducing inappropriate CTs, PET scans, or MRIs.

"[PA reviews] need to be a discussion about performance measures, not anecdotal information," says Sallee.

Provide frequent feedback, as often as once monthly for new PAs. Most new PAs are very green and need much mentoring and handholding at the beginning. Monthly, quarterly, or annual meetings might be more appropriate for more experienced PAs, says Michelman.

If your PA doesn't meet targets, try to determine why. It might not always be the PA's fault, he says. "Maybe the goals are not reasonable," says Michelman says. "Maybe they're the wrong goals."

A systemic problem at work might exist.

PAs sometimes don't have proper support to enforce changes. Establish a process for the hospital medical staff and board to follow up with noncompliant physicians. A PA who doesn't have the support of the medical board will have less power to perform effectively.

"You need a good PA but you also need good protection for that PA," says Michelman.

Working with a problem PA

Conversely, the problem might be the PA. Perhaps the PA isn't a team player. Maybe there isn't adequate time to perform the job. Maybe the PA won't take on "protected physicians," Michelman says.

In these situations, revisit the goals and set a time frame for the next review. If there isn't substantial improvement, it may be time to end the relationship.

Some problems may be due to a training gap, says Sallee. "When it comes to educating physician advisors, unfortunately there's not a whole lot of training information out there." Organizations often must develop their own programs and materials in this area, she says, noting that PA conferences can be helpful. "What I've typically done is taken physician advisors to conferences in the past. We discussed what was presented and how it affects us or how we're doing."

Offering incentives for improvement can boost performance. "Most organizations I have worked in have annual goals and also a bonus incentive process," says Sallee. This incentive process provides PAs target goals and additional compensation for meeting them.

Knowing when it's time to move on

Ultimately, however, even if you provide them additional training and education, the position may not be a good fit for certain individuals. If you suspect this is the case, it may be necessary to sever the relationship. Don't wait to do this, says Michelman. Organizations sometimes delay too long before cutting ties. Doing so limits your organization's ability to improve and progress.

Don't be afraid to make a change. It's important to have the right person in this job. If you don't, the efficiency of your organization will suffer.

Physician advisor job description

Position summary

Conducts clinical review on cases referred by case management staff and/or other healthcare professionals in accordance with the hospital's objectives for ensuring quality patient care and effective, efficient utilization of healthcare services, and to meet regulatory requirements. Meets with case management and healthcare team members to discuss selected cases and make recommendations for care. Interacts with medical staff members and medical directors of third-party payers to discuss the needs of patients and alternative levels of care. Acts as consultant and resource to attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. Acts as consultant and resource to the medical staff regarding federal and state utilization and quality regulations.

Principal duties and responsibilities

Reviews medical records of patients identified by case managers or as requested by the healthcare team to:
- Assist with level of care and LOS management
- Assist with the denial management process
- Review and make suggestions related to resource and service management
- Assist staff with the clinical review of patients
- Determine whether professionally recognized standards of quality care are met
Provides feedback to attending and consulting physicians regarding level of care, LOS, and quality issues. Seeks additional clinical information from attending and consulting physicians. Recommends and requests additional, more complete medical record documentation. Recommends next steps in coordination of care and evidence-based medicine indicators.
Serves on the medical staff committee that oversees utilization management.
Reviews cases that indicate a need for issuance of a hospital notice of noncoverage/Important Message from Medicare. Discusses the case with the attending physician and if additional clinical information is not available, discusses the process for issuance and appeal to the physician.
Provides education about regulatory requirements, appropriate utilization, alternate levels of care, community resources, and end-of-life care to physicians and other clinicians. Works with physicians to facilitate referrals to the continuum of care.
Documents patient care reviews, decisions, and other pertinent information in accordance with hospital policy. Understands and uses InterQual® and other appropriate criteria. Documents response to case management referrals in the computer system.
Notifies the case manager of any conflict of interest in reviewing a particular patient record. Assists with identifying a physician to review such record.
Serves as liaison with payers to facilitate approvals and prevent denials or carved-out days when appropriate. Facilitates, mentors, and educates other physicians regarding payer requirements.
Participates in review of long-stay patients, in conjunction with the director of case management, to facilitate the use of the most appropriate level of care.
Chairs or serves on the case management and/or utilization management committee.

Additional job functions

Participates in the peer review process; suggests ways to improve this process
Assists with evaluation of the hospital utilization management program
Maintains current knowledge of federal, state, and payer regulatory and contract requirements
Attends continuing education sessions pertaining to utilization and quality management
Meets with corporate and hospital case management staff as needed

Minimum qualifications

Education: Graduate of an accredited medical school. Additional education in quality and utilization management through continuing medical education programs and self-study.

Experience: Minimum of five years recent experience in clinical practice. Utilization management experience as a member of the UM oversight committee or past physician advisor experience preferred.

Certificate/license:Current license to practice medicine in state where health system is located and eligibility for active membership on the hospital medical staff.

Physical demands:Ability to travel to various hospital locations, including patient care areas, conference facilities, health system office, and other sites as requested.

Work environment: Office and patient care areas.

Supervisor: Vice president of case management for administrative supervision, chief medical officer, or lead physician advisor for clinical supervision.

Source: Linda Sallee, MS, RN, CMAC, ACM, IQCI, director, Huron Healthcare. Adapted with permission.

Understand home health rules for better care

Fri, 01 Jun 2012 04:00:00 GMT

Understand home health rules for better care

For many patients, home health services can mean the difference between a successful recovery and a hospital readmission.

But, patients who need services go without because of confusion over eligibility requirements, says Jackie Birmingham, RN, MS, CMAC, BSN, vice president emeritus of clinical leadership at Curaspan Health Group in Newton, Mass.

"Hospitals are sometimes more restrictive than they need to be," says Birmingham. And sometimes home health agencies are overly conservative out of fear that patients won't qualify for services, says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of The Center for Case Management in Wellesley, Mass.

Patients ultimately pay the price.

Is this the case at your organization? It may be time to examine your home health policies and processes.

Eligibility standards for home health services

The government currently defines patients as "homebound" and eligible for home health services if they are only able to leave home infrequently for short periods of time, says Birmingham. Patients are still eligible if they leave their home for a physician appointment, for example. But people sometimes wrongly assume that if they leave the home for any reason they don't qualify, she says.

When considering this issue, determine how your organization defines eligibility for home health services. Compare that definition to the existing standards and update your policy if necessary, says Zander.

Also consider how other home health agencies in your area interpret eligibility requirements for homecare. Ensure that the policies are not unnecessarily restrictive, says Zander. The case management director should meet with external organizations and request changes if problems are discovered.

Communication lines with these organizations should remain open going forward.

"If a patient is in a gray area, the goal is to not arbitrarily say that they're not eligible for homecare," says Zander. In these situations, case managers and home health staff should meet to determine whether a patient qualifies.

Understand patient history

Case managers should ensure that patients aren't missing out on homecare services by obtaining a thorough patient history upon admission.

Spend time asking detailed questions about patients' social and medical histories. "It's not enough to ask if they live alone," says Birmingham. Case managers also need to know at the time of admission whether the patient received home healthcare in the past. If they did, what went wrong that led to the readmission?

Obtaining this information early can help identify potential problems patients might have caring for themselves at home. If you don't ask the right questions, you might not be aware of these issues. Being armed with detailed information can also help you identify home health services that will benefit patients and reduce the risk of readmission.

Refer patients carefully

Home healthcare can greatly benefit patients, but it is also an area that has great potential for fraud, says Birmingham. For example, avoid problems by working with organizations that are accredited by The Joint Commission, she says. When you refer patients, ensure that the recommended agency is licensed. Also, inform patients and their families that they should carefully check references for any nonmedical support services for which their state does not require a license. Refer to CMS Home Health Compare at www.medicare.gov/HomeHealthCompare/search.aspx?AspxAutoDetectCookieSupport=1.

Focusing on home health services in your area and confirming patient eligibility can help patients recover successfully at home. It may also benefit your organization by reducing readmissions.

When your organization is reviewing its home healthcare policies, note that the definitions of homecare eligibility may change in the near future, says Jackie Birmingham, RN, MS, CMAC, BSN, vice president emeritus of clinical leadership at Curaspan Health Group in Newton, Mass.

The federal government is preparing a final rule, which was proposed in the July 12, 2011, Federal Register at www.gpo.gov/fdsys/pkg/FR-2011-07-12/html/2011-16937.htm.

The rule would expand home healthcare eligibility to more patients. Under the proposal, patients would no longer need to be "homebound" to qualify for services. In addition, eligible services could also be provided outside the home, says Birmingham.

For example, this new definition would include patients who are able to be more independent outside the home, but have a wound that requires skilled care, says Birmingham.

"It wouldn't apply to everybody [who might benefit from home services] but I think it supports the government's initiative to keep people out of nursing homes. It might … make home care more accessible and eligibility more meaningful," she says.

The goal of this rule is to help more patients, who might otherwise require a nursing home placement, to remain at home. The benefit to the government would be lower-cost care and improved patient satisfaction.

Until publication of the final rule, it remains to be seen exactly how the regulations will change. Case Management Monthly will continue to monitor developments. Meanwhile, ensure that your current practices don't deny patients needed care, says Birmingham.

Team approach benefits Maine healthcare organization

Fri, 01 Jun 2012 04:00:00 GMT

Team approach benefits Maine healthcare organization

After reading this article, you will be able to:

Explain how a team approach can benefit the case management process
Develop strategies to create a team model at your organization and avoid pitfalls associated with the process

Case managers at Martin's Point Health Care in Portland, Maine, worked independently in the past. Today they work on three teams, a change that has helped reduce readmissions and improve patient satisfaction.

It began in 2011 as a pilot program consisting of just one team. The program is now permanent.

Improving the hospital experience for patients, improving the quality of care, and reducing costs were the goals, says Sonia Tyler, RN, CCM, PAHM, CPUR, a case manager responsible for utilization management of acute inpatient and outpatient services at Martin's Point.

Previously, case managers had specific, well-defined roles (e.g., benefit or utilization review). Everyone had a specific job and there wasn't much communication, says Erin Corbin, RN, BSN, CCM, a nurse case manager at Martin's Point.

Organizing the teams

The teamwork initiative changed the system drastically. Staff members now work in teams instead of alone. Team members include case managers, concurrent review nurses, and health coaches who work together on patient cases, says Corbin. Cross-training helps them understand the roles of other team members.

Currently, there are three separate teams in the health management department, says Corbin. Each team focuses on a different geographical area, says Tyler. This allows team members to become familiar with available resources at specific locations and streamlines the process of matching patients with services.

The new teams also reduce the recurrence of prior problems. For example, because staff members didn't communicate as effectively with one another in the past, patient information might slip through the cracks. This was sometimes the case when cases moved from a home case manager to utilization review. As a result, patient care was more fragmented. The new approach increases communication and has eliminated many of these problems. A team works together on a patient case from beginning to end.

Each team also has its own pharmacy representative to help sort through patient medication issues. These pharmacy representatives offer suggestions to reduce the cost of medications and to ensure patients have access to the medication they need. Medication issues are a major cause of readmissions at many hospitals, and this program is helping to eliminate related issues, says Tyler.

Teams have regularly scheduled meetings and ad hoc meetings to address specific topics, such as how to improve a particular process at the organization to increase efficiency. They meet individually and with the other two teams to share ideas, says Tyler.

The teams' foundation and tools are standardized. For example, they all rely on Milliman Care Guidelines®. But in other ways the teams have evolved differently. Different teams might decide to meet at different intervals or assign tasks differently. "[My team] meets every other week to discuss process changes and to check in to see how everyone's doing," says Corbin.

Teams brainstorm for process changes to improve efficiency and patient care. For example, one change was designed to improve communication with patients undergoing elective procedures. "Previously, we had no contact with the patient preoperatively," says Tyler. Team members now reach out to ensure patients are prepared for surgery and to determine if special accommodations are necessary. This facilitates discharge planning even before patients arrive at the hospital. Case managers know whether any potential issues that require planning exist at the outset.

The teams also established a process to follow patients after discharge. Team members follow up to verify that patients have scheduled appointments and have access to necessary medications. They help patients manage health issues that may affect recovery (e.g., diabetes).

Teamwork pays off

Martin's Point is still collecting and analyzing data to assess how well the teams are working, but it has seen its readmission rate decrease as a result of the new model. It also anticipates improved satisfaction rates.

The team method has produced benefits, but it's not an easy program to get up and running, says Corbin. "It's difficult to pull all the different personalities together and try to unify a workforce," she says.

Organizations that want to try something similar should designate one person, preferably with human resources experience, to help guide the process, Corbin says. Martin's Point didn't have someone in this position; it would have helped immensely, says Tyler.

Create a game plan

Use these strategies for an effective team approach:

Focus on patients. A common focus keeps the process grounded; remember who it's designed to benefit, says Tyler.
Establish a clear vision. Know what you want to accomplish. Without a foundation, it's easy for the process to go haywire, says Corbin.
Anticipate resistance. Garnering case manager support was a major challenge. Change is difficult, and this particular change was substantial. Some individuals embraced it, others struggled, and several left their jobs, says Tyler. It's normal for some people to reject a new model when large-scale change occurs, she says.
Allow sufficient time. It will take many months to transition to a team model, says Corbin. "Don't underestimate how long it takes," she says.

Team model broadens individual perspective

Overall, the team model provides a clearer vision of the big picture. "It allows us to get to know other job functions. We always had seen bits and pieces of what others do, but this allowed us greater respect for what our colleagues do," says Corbin. "It's definitely made our communication pathways more open."

The team model has provided an added benefit: Working together toward a common goal has put a new emphasis on keeping patients well, says Tyler.

Kate Anthony, RN, MSN, CCM, manager of benefit review at Martin's Point Health Care in Portland, Maine, provides the following sample agenda topics from previous case management team meetings at her facility:

Hospice-Discussions focus on coordinating levels of hospice care to meet patients' needs.
Transitions of care-Discussions focus on member transitions from any setting (e.g., home to assisted living, patients who will remain at home and receive additional support services).
Readmission prevention-Outreach is provided to select patients within 48 hours of discharge from any inpatient stay. Discussions focus on home assessment, scheduling follow-up appointments, medications, home health agency involvement, and case management outreach to primary care physicians or home health agencies as needed.
Disease management-Staff members assess patients' current chronic disease state (e.g., diabetes, frequency of blood sugar monitoring, medications, exercise) and discuss follow-up appointments.
Preoperative calls-Certain patients receive these calls; discussions focus on outcomes related to them.

Case Management Monthly, June 2012

Fri, 01 Jun 2012 04:00:00 GMT

Ensure the right fit when hiring a physician advisor

After reading this article, you will be able to:

Identify the qualities an individual needs to be a strong physician advisor (PA)
Develop strategies for assessing PA performance, providing training, and learning when it's time to sever a PA relationship

Your physician advisor (PA) provides a critical link between case management and physicians. It's a job that requires deft communication skills, regulatory know-how, and a stiff backbone.

Not all physicians are cut out to be PAs, says Linda Sallee, MS, RN, CMAC, ACM, IQCI, director of Huron Healthcare in Chicago. And many physicians don't actually want the job, she says.

For case managers, getting the right person for the job can pay big dividends-shorter LOS, fewer denials, and more appropriate use of medical tests.

It takes skill to find a good match. The following strategies can help you hire the right PA, improve existing PAs' skills, and know when it's time to replace a PA who isn't working out.

Hiring a strong advisor

The best way to ensure you have a strong physician advisor is to hire carefully, says Sallee.

Michelman suggests looking for candidates with the following skills and experience:

Has been a member of the medical staff for several years
Is familiar with "untouchable physicians" who bring great value, but can be difficult to manage
Enjoys the respect of colleagues and is viewed as credible by them
Can commit the necessary time to the role
Is willing to confront colleagues when necessary

Looking for PA candidates on the job

Helping your PA improve

"[PA reviews] need to be a discussion about performance measures, not anecdotal information," says Sallee.

If your PA doesn't meet targets, try to determine why. It might not always be the PA's fault, he says. "Maybe the goals are not reasonable," says Michelman says. "Maybe they're the wrong goals."

A systemic problem at work might exist.

"You need a good PA but you also need good protection for that PA," says Michelman.

Working with a problem PA

Conversely, the problem might be the PA. Perhaps the PA isn't a team player. Maybe there isn't adequate time to perform the job. Maybe the PA won't take on "protected physicians," Michelman says.

In these situations, revisit the goals and set a time frame for the next review. If there isn't substantial improvement, it may be time to end the relationship.

Knowing when it's time to move on

Don't be afraid to make a change. It's important to have the right person in this job. If you don't, the efficiency of your organization will suffer.

Physician advisor job description

Position summary

Principal duties and responsibilities

Reviews medical records of patients identified by case managers or as requested by the healthcare team to:
- Assist with level of care and LOS management
- Assist with the denial management process
- Review and make suggestions related to resource and service management
- Assist staff with the clinical review of patients
- Determine whether professionally recognized standards of quality care are met
Provides feedback to attending and consulting physicians regarding level of care, LOS, and quality issues. Seeks additional clinical information from attending and consulting physicians. Recommends and requests additional, more complete medical record documentation. Recommends next steps in coordination of care and evidence-based medicine indicators.
Serves on the medical staff committee that oversees utilization management.
Reviews cases that indicate a need for issuance of a hospital notice of noncoverage/Important Message from Medicare. Discusses the case with the attending physician and if additional clinical information is not available, discusses the process for issuance and appeal to the physician.
Provides education about regulatory requirements, appropriate utilization, alternate levels of care, community resources, and end-of-life care to physicians and other clinicians. Works with physicians to facilitate referrals to the continuum of care.
Documents patient care reviews, decisions, and other pertinent information in accordance with hospital policy. Understands and uses InterQual® and other appropriate criteria. Documents response to case management referrals in the computer system.
Notifies the case manager of any conflict of interest in reviewing a particular patient record. Assists with identifying a physician to review such record.
Serves as liaison with payers to facilitate approvals and prevent denials or carved-out days when appropriate. Facilitates, mentors, and educates other physicians regarding payer requirements.
Participates in review of long-stay patients, in conjunction with the director of case management, to facilitate the use of the most appropriate level of care.
Chairs or serves on the case management and/or utilization management committee.

Additional job functions

Participates in the peer review process; suggests ways to improve this process
Assists with evaluation of the hospital utilization management program
Maintains current knowledge of federal, state, and payer regulatory and contract requirements
Attends continuing education sessions pertaining to utilization and quality management
Meets with corporate and hospital case management staff as needed

Minimum qualifications

Education: Graduate of an accredited medical school. Additional education in quality and utilization management through continuing medical education programs and self-study.

Experience: Minimum of five years recent experience in clinical practice. Utilization management experience as a member of the UM oversight committee or past physician advisor experience preferred.

Certificate/license:Current license to practice medicine in state where health system is located and eligibility for active membership on the hospital medical staff.

Physical demands:Ability to travel to various hospital locations, including patient care areas, conference facilities, health system office, and other sites as requested.

Work environment: Office and patient care areas.

Supervisor: Vice president of case management for administrative supervision, chief medical officer, or lead physician advisor for clinical supervision.

Source: Linda Sallee, MS, RN, CMAC, ACM, IQCI, director, Huron Healthcare. Adapted with permission.

Understand home health rules for better care

For many patients, home health services can mean the difference between a successful recovery and a hospital readmission.

Patients ultimately pay the price.

Is this the case at your organization? It may be time to examine your home health policies and processes.

Eligibility standards for home health services

Communication lines with these organizations should remain open going forward.

Understand patient history

Case managers should ensure that patients aren't missing out on homecare services by obtaining a thorough patient history upon admission.

Refer patients carefully

Focusing on home health services in your area and confirming patient eligibility can help patients recover successfully at home. It may also benefit your organization by reducing readmissions.

The federal government is preparing a final rule, which was proposed in the July 12, 2011, Federal Register at www.gpo.gov/fdsys/pkg/FR-2011-07-12/html/2011-16937.htm.

For example, this new definition would include patients who are able to be more independent outside the home, but have a wound that requires skilled care, says Birmingham.

Team approach benefits Maine healthcare organization

After reading this article, you will be able to:

Explain how a team approach can benefit the case management process
Develop strategies to create a team model at your organization and avoid pitfalls associated with the process

It began in 2011 as a pilot program consisting of just one team. The program is now permanent.

Organizing the teams

Teamwork pays off

Create a game plan

Use these strategies for an effective team approach:

Focus on patients. A common focus keeps the process grounded; remember who it's designed to benefit, says Tyler.
Establish a clear vision. Know what you want to accomplish. Without a foundation, it's easy for the process to go haywire, says Corbin.
Anticipate resistance. Garnering case manager support was a major challenge. Change is difficult, and this particular change was substantial. Some individuals embraced it, others struggled, and several left their jobs, says Tyler. It's normal for some people to reject a new model when large-scale change occurs, she says.
Allow sufficient time. It will take many months to transition to a team model, says Corbin. "Don't underestimate how long it takes," she says.

Team model broadens individual perspective

The team model has provided an added benefit: Working together toward a common goal has put a new emphasis on keeping patients well, says Tyler.

Hospice-Discussions focus on coordinating levels of hospice care to meet patients' needs.
Transitions of care-Discussions focus on member transitions from any setting (e.g., home to assisted living, patients who will remain at home and receive additional support services).
Readmission prevention-Outreach is provided to select patients within 48 hours of discharge from any inpatient stay. Discussions focus on home assessment, scheduling follow-up appointments, medications, home health agency involvement, and case management outreach to primary care physicians or home health agencies as needed.
Disease management-Staff members assess patients' current chronic disease state (e.g., diabetes, frequency of blood sugar monitoring, medications, exercise) and discuss follow-up appointments.
Preoperative calls-Certain patients receive these calls; discussions focus on outcomes related to them.

Barrier reduction teams improve efficiency at NewYork-Presbyterian

Tue, 01 May 2012 04:00:00 GMT

Barrier reduction teams improve efficiency at New York-Presbyterian

Explain the strategy of New York-Presbyterian Hospital's barrier reduction teams
Demonstrate ways to use barrier reduction teams to increase communication and reduce LOS

If your facility has factors that slow down the patient discharge process, your frontline staff members likely have a good idea of the problems. However, frontline staff at most facilities do not have the means to communicate the problems or help make improvements.

At New York-Presbyterian Hospital in New York City, this is no longer the case.

Leaders there established multidisciplinary barrier reduction teams (BRT) in late 2009, which are designed to increase efficiency and improve communication at the organization. The teams give staff members a way to speak up about issues that may hinder patient care and the discharge process.

The team dynamic

Each BRT at New York-Presbyterian focuses on a different service area. The hospital has nine teams that cover areas such as pediatrics, cardiac, and general surgery.

"It's not just nursing or case management that collaborates; it's everyone who cares for the patient working together to improve efficiency," says Suzanne Boyle, RN, DNSc, vice president of patient care services at New York-Presbyterian.

Some of the teams include physician coleaders.

All the teams meet every other week for about a half hour, says Boyle. The hospital designed the meetings to be quick and provide an overview of efforts that are under way.

"In between meetings, the leaders are making sure that the initiatives they talked about are getting done," she says. In addition, group leaders meet with each other monthly to discuss best practices that might be useful to the other BRTs.

Boyle cautions that not all best practices are applicable to every team.

"What works in pediatrics might not work for cardiac," she says.

The teams' ultimate purpose, though, is to make use of information from staff members who work with patients each day.

"It's giving them the power to identify and create solutions to issues, inspiring them to be innovative," says Kate Pavlovich, quality improvement manager in the division of patient safety, quality improvement, and innovation at New York-Presbyterian.

Giving staff members a voice allows them to take action, adds Carol DeJesus, LCSW, CCM, director of social work and care coordination at the facility.

"One of the social workers in the cardiac service line spoke recently about how empowered these meetings made her feel," says Pavlovich. "In the past, she didn't feel like she had a forum to talk about any of these issues or to proactively address them."

Making change

The BRTs want to question the status quo and find more efficient ways to do things.

As a result, the teams have brought down some "sacred cows" within the organizations-things that weren't questioned in the past, says Boyle.

For example, team members suggested moving the time that physicians performed patient rounds. In the past, the organization considered the time designated for rounds to be untouchable. However, the added flexibility in this area has improved the rounds' efficiency.

DeJesus says the organization has also changed how the physical therapy department forms its referrals and treatment plans, and how social workers interact with nursing teams. Additionally, the BRT in orthopedics helped establish new clinical pathways that have reduced LOS, she says. While physicians sometimes resist using clinical pathways or prescribed treatment patterns because these tools infringe on their autonomy, in this case the physicians agreed to their use-primarily because they helped design them and thus understood the benefits, DeJesus says.

Ultimately, the BRTs at New York-Presbyterian have led to:

Reduced LOS
Increased communication between patient care providers
More efficient handoffs at discharge

The BRTs are also more engaged with the IT department, which provides team members with real-time data to analyze their efforts, says Boyle.

Using this data, the teams continually assess how well initiatives are working and take lessons from less-successful plans.

Putting the program into action

If you're looking to start a BRT program at your own facility, you must first gain the support of leadership. You must also understand that these groups are not a place to lay blame.

"The goal is not to go around pointing fingers and saying, 'You have to fix this,' " says DeJesus.

Remember to do the following when initiating a BRT program:

Keep meetings short. Meetings should be no longer than half an hour, and their agendas should be streamlined accordingly.
Don't fear failure. New York-Presbyterian learns from trial and error. If an initiative doesn't work, the organization moves on and finds one that does, says Boyle.
Listen to those on the front lines. Help your frontline staff share the information they gather daily. Putting this information into action will enable your organization to make strides toward improving how its systems work.

Future goals

New York-Presbyterian's BRTs will continue to work at the facility going forward. Organization leaders want to further reduce the facility's LOS while continuing to ensure that patients are discharged safely and get the aftercare they need, says DeJesus.

Avoiding sticky legal issues during discharge

Tue, 01 May 2012 04:00:00 GMT

Avoiding sticky legal issues during discharge

Explain legal issues that may be encountered during the discharge process
Avoid potential legal problems associated with patient discharges

Making sure patients are prepared for discharge can be a tricky process. When certain laws are considered, getting patients to their next destination becomes even more complex.

Whether it's guardianship disputes or patients ignoring medical advice, case managers often face legal issues. But you can protect both the patient and your organization by using the following strategies to manage some of the most common legal complications:

Understand legal documents. One of the most important roles of the social worker and case manager is to identify discharge barriers early. For example, a patient might be admitted for care but have no capacity to make decisions or to care for him or herself in the community. In such a case, the case manager and/or social worker should determine whether there are any legal documents identifying a person with authority to make decisions for the patient, says Alexandra Trinkoff, senior associate general counsel at the North Shore-LIJ Health System, based in Great Neck, N.Y.

"The legal relationship could be incorrectly interpreted if this step isn't taken," says Trinkoff.

For example, a patient might have paperwork showing that another individual has power of attorney. Often, though, the power of attorney only applies to financial decisions, not medical ones.

Failure to understand this distinction may delay care and discharge, says Trinkoff. Thus, reviewing the legal documents early in a patient's admission can help identify potential barriers to discharge planning, she says, adding that any conflicts can often be cleared up in a family meeting.

Establish guardianship. Whether you're trying to remove a guardian who isn't acting in the patient's best interests or getting the patient to accept a new guardian, you will often find yourself in prickly legal territory, says Trinkoff.

The same is true if the patient has family who objects to the patient's discharge; they may not want to put their loved one in a nursing home or, conversely, be fearful of caring for the patient at home.

While it may be tempting to have a court sort through the mess, in general it's best to avoid dragging these cases into the legal system, says Trinkoff.

"The court is not really set up to handle these decisions as quickly as they need to be made when they are related to medical issues," she says. "The court is more appropriate for a long-term process."

Instead, meet with the patient's family or friends. Work through the issues and offer willing individuals the ability to support the patient whenever possible, says Tracy Moore, director of social work at North Shore University Hospital in Manhasset, N.Y.

Also consider planning ahead to avoid trouble with guardianship issues during future visits.

"I think one of the things we try to do upon admission is to talk to the patient about who they want as a healthcare proxy for the future and be more proactive about their wishes so they can be put in place for the future," says Moore.

Uphold patient rights. Case managers will sometimes run into situations where a patient wants to make a decision that is not in his or her best interest. For example, a homeless patient might want to be discharged back onto the street.

"As long as they have the capacity, they should be permitted to make that decision," says Trinkoff.

But while healthcare providers ultimately need to give patients this choice, they must also protect themselves if the patient experiences an adverse event related to his or her discharge. Document the details of the patient's decision and the steps taken by the case manager and social worker to mitigate risks, including a possible referral to adult protective services or a community case manager.

Ensure that the patient truly understands the implications of his or her decision by providing education. Use the teach-back method whenever possible. This involves the patient repeating information back to instructors in his or her own words, which helps make certain the patient understands the material.

"Sometimes this might change the patient's mind," says Moore.

For example, a patient might not truly understand the benefits of homecare due to not knowing what it involves. Educating the patient on the homecare process might make him or her more likely to accept the necessary help.

Provide patients with choices. Case managers should allow patients to choose their own postacute care facility or service. The government mandates that patients be given a choice of providers.

"At North we give them a list of [postacute care providers]," says Joanne Rocco, director of case management at North Shore University Hospital. But they also provide the patient with information to help them gauge the quality of postacute care service on the government's Medicare.gov website. This site uses a star system to rank facilities, which allows the patient to determine for themselves whether this is a facility they want to go to, she says.

"Sometimes, choice is limited based on the patient's needs and/or the patient's insurance.

"However, we try to provide patients with the necessary resources so they are able to make an informed decision."

Overcome challenges related to undocumented individuals. Undocumented immigrant patients aren't typically eligible for government support services. Identifying these patients early is important, though, because there may be legal recourse to provide them with benefits, says Trinkoff.

Some nongovernmental groups, charities, or religious organizations might also offer services.

Ultimately, there may be many perils when it comes to discharge, but early intervention with patients can make a huge difference.

"Every single patient has their own challenges," says Trinkoff. "It's important to get them appropriate resources so that they can be well taken care of when they leave."

Take control to reduce the strain from audits

Tue, 01 May 2012 04:00:00 GMT

Take control to reduce the strain from audits

Analyze new audit responsibilities and their effect on case managers
Demonstrate new strategies to help streamline the audit process

Case managers have already become familiar with the Medicare Recovery Audit Program. In January, however, government Recovery Auditors began focusing on new territory: Medicaid claims.

CMS mandated the Medicaid audits under a provision of the Patient Protection and Affordable Care Act. Access the final rule, published in the Federal Register September 16, 2011, at https://federalregister.gov/a/2011-23695.

The good news: The Medicaid audits are similar to Medicare audits, and case managers can prepare for them in the same way.

The bad news: With more of these audits cropping up, case managers are increasingly being pulled away from the bedside, says June Stark, RN, BSN, M.Ed., director of case management and quality support services at Tufts Medical Center in Boston.

While you can't make these audits disappear, you can help manage them by contributing to your organization's Recovery Audit team and planning your new workload, says Stark.

Below are some tips to help you stay ahead of your audit-related responsibilities and thwart problems that may trigger audits:

Form a team. "The best way to prepare for the Recovery Audit, or any audit, is to begin by identifying who will be the lead in your institution and then establishing a strong collaboration between all the departments who will be involved in your hospital's RAC process," says Stark. An effective team includes representation from:
- Medical records
- Patient accounts
- Coding
- Admitting
- Compliance
- Case management
Consider your workload. Plan ahead to make sure you don't become overwhelmed by audits. Assess your department's staffing needs to determine whether you will need additional help with the increased workload, says Stark.

Remember that a Recovery Audit is an ongoing process once triggered, she says. Unlike other types of audits, which can often be wrapped up in a matter of months, a Recovery Audit doesn't have a definite completion date.

"Approximately 200 charts can be requested every eight weeks, indefinitely," says Stark. "So cases can be in multiple stages of the review and appeal at the same time for years."

As a result, case managers can quickly find themselves buried in requests. When you consider staffing needs, plan for a worst-case scenario. Also, consider upgrading your computer software to help your department track and manage the stages of each audited case, says Stark.

Get ready to act quickly. If you receive a request for additional documentation, respond to the inquiry quickly, says Suzanne Lash, director of health information management at Fisher-Titus Medical Center in Norwalk, Ohio.

Know the response process and assign designated roles to staff members, says Stark. When forming your Recovery Audit response group, make certain that everyone on the team understands the regulations and guidelines. Develop a flow chart that clearly demonstrates the responsibilities of each individual and outlines the internal audit processes, says Stark. This will eliminate confusion and duplicate work, allowing your organization to answer requests as quickly as possible.

Focus on problem areas. Recovery Auditors often focus on specific areas where many organizations fumble. For example, auditors will likely target inpatient versus observation status assignments, says Lash. Take time to understand and assess the risk areas on which the Recovery Auditors focus.

"We put a system in place to track all the RAC audits that we have," says Kristi Washburn, MOL, BSNi, director of quality and case management at Fisher-Titus Medical Center. "Doing so helps you spot trends, and it can help you get a better picture of what you can do in the future to mitigate risks."

Remember that a Recovery Audit won't just stick to current events-auditors also look back to old claims. This means that even if you found a problem and recently fixed it, there may be earlier claims affected by that problem that can come back to haunt your organization.

Consider rebilling. If you find that you have billed incorrectly in the past, it's not too late to take action, says Lash. "If you think a claim is going to be denied, it may be worth trying to rebill it," she says. For example, if you believe a patient may not have qualified for an inpatient stay, you can rebill for services that would have been approved for an outpatient visit.

You may want to stick with newer cases for this strategy, but it may still be worth trying on the older ones, notes Lash.

Adjust your tactics. Due to Recovery Auditor scrutiny on issues such as medical necessity and inpatient versus observation status, case managers at Fisher-Titus Medical Center now target these areas. "We're redesigning our case management program so that we can have more focus on clinical documentation and the [utilization review] aspect of making sure patients are assigned the correct status," says Washburn.

The case managers determine what constitutes an observation stay and what constitutes an inpatient stay, but they also ensure that they have the documentation to back up the physician's decision.

"A patient may very well meet the criteria for an inpatient stay, but it isn't valid unless you have the documentation to go along with it," Washburn says.

Don't be afraid to appeal. Don't just accept the word of a Recovery Auditor without doing your own investigation. "We look at each issue and weigh it considering the cost versus the time it takes to appeal it," says Washburn. Many times appealing pays off.

To streamline your appeals, outline the appeals process and establish organizationwide criteria to decide whether a case will be appealed, says Stark. Having this process in place can reduce the amount of time it takes to make appeal decisions.

As the number of audits increases, case managers must stay organized and plan ahead. Doing so will reduce the audit toll on your department and help you stay where you belong-at the bedside working with patients.

Feeling the heat: Providers share their experience with Recovery Audit Program and other audits

Tue, 01 May 2012 04:00:00 GMT

Feeling the heat: Providers share their experience with Recovery Audit Program and other audits

Editor's note: Each year HCPro's Revenue Cycle Institute reports on the experience of providers related to the Recovery Audit Program. The article below is adapted from the 2011 Recovery Auditor Benchmarking Report, released in early 2012. The summary of last year's results is by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro. Readers can download their complimentary copy of the full report at www.revenuecycleinstitute.com.

It's been quite an eventful year in the world of Recovery Auditors.

This year's survey had 431 respondents representing hospitals of all sizes and from all four Recovery Auditor regions. Respondents were fairly evenly distributed among providers of different sizes, with 21% from small hospitals with less than 100 beds and 31% from larger hospitals with more than 400 beds. Region C had the most respondents, and there was an increased response from Regions A and D, although all regions were fairly well represented.

The responses reflect a big uptick in Recovery Auditor activity with a large increase in respondents reporting both automated audits and records requests.

Less than 50% of providers had received an automated audit recoupment last year, but this number is now up to 72%. (See Figure 2 below.)

In addition, more than 80% of providers have received records requests for semi-automated or complex reviews over the course of 2011.

This increase in audit activity has led to an increase in the respondents who have had money recouped. Seventy-six percent of respondents have experienced recoupment, leaving only 6% of providers who have received records requests unscathed by recoupments.

With the increase in activity of the Recovery Auditors, however, we have seen a corresponding decrease in problems with the operations of the Recovery Audit Program as issues have worked themselves out as predicted in last year's report.

For example, the number of respondents having problems with records requests fell from 17% to 8%; other issues related to records requests, other than tracking, were also cited by fewer than 10%.

The most challenging issues cited by providers are demand letters (21%), tracking recoupments back to individual claims (17%), and the discussion period (16%), all of which CMS has taken steps to address. Beginning in January 2012, demand letters are issued by the Medicare Administrative Contractor (MAC) rather than the Recovery Auditors to ensure the timing is accurate for recoupments related to the demand letter.

CMS also made changes to the discussion period in the new September 2011 scope of work for the Recovery Auditors.

Providers also saw substantial audit activity by other contractors in addition to Recovery Auditors. Thirty-five percent of respondents have seen audits from the Comprehensive Error Rate Testing program.

The number of MAC probe audits seemed relatively low at 16%, but 16% of respondents have also had audits from the Office of Inspector General (OIG)-a relatively high number considering how focused OIG audits tend to be.

In addition to the Medicare arena, we are also seeing audit activity from Medicaid, with 16% of respondents having received Medicaid Integrity Contractor audits and 5% having received audits from Medicaid Recovery Auditors.

Additionally, several respondents indicated via write-in answers that they are experiencing audit activity from managed care plans.

All of this activity has led to the development of audit departments to handle government audits. The survey shows that most respondents with programs to handle recovery audits make them part of larger programs that handle all government audits (49%), with even more indicating through write-in answers that they are in the process of doing so.

As programs to handle audits have matured, the position of audit program coordinator has shifted from a director-level position to a staff-level position. This shows that respondents' audit programs have graduated from the development and policymaking stage, and that coordinators are now dealing with the daily operational tasks of responding to audits.

Providers' preparations continue to focus on inpatient medical necessity and one-day stays, with 34% of respondents indicating they are continuing to address this area.

Thirteen percent of respondents report that they are working on appeals processes and observation, with DRG coding validation cited as a focus area by 12% of respondents.

The continued emphasis on inpatient medical necessity has led to more than 50% of respondents working with their case management departments to tighten utilization review (UR) controls.

In fact, 87% of respondents have an active UR committee, and more than 50% have a representative from that committee involved in medical necessity determinations on a daily basis.

As for appeals, 90% of providers have a program in place to handle the process. Most are handling them internally, either through a dedicated department (23%) or through the staff of the affected department (34%).

An additional 35% use a combination of internal and external staff, and a mere 5% are outsourcing their appeals to external entities, which is fairly consistent with 2010's data.

With the increase in audit activity, more providers are preparing financially for potential recoupments. More than half of respondents report setting aside funds in case of recoupments, in amounts ranging from $100,000 to $14 million.

Overall, respondents demonstrate that they have mature audit and appeals programs to handle the increased volume of recovery audits and other government audits they are receiving.

This will benefit providers as the Recovery Audit Program expands to prepayment audits in 2012 and the Medicaid Recovery Audit Program gets under way.

Case Management Monthly, May 2012

Tue, 01 May 2012 04:00:00 GMT

Barrier reduction teams improve efficiency at New York-Presbyterian

Explain the strategy of New York-Presbyterian Hospital's barrier reduction teams
Demonstrate ways to use barrier reduction teams to increase communication and reduce LOS

At New York-Presbyterian Hospital in New York City, this is no longer the case.

The team dynamic

Each BRT at New York-Presbyterian focuses on a different service area. The hospital has nine teams that cover areas such as pediatrics, cardiac, and general surgery.

Some of the teams include physician coleaders.

All the teams meet every other week for about a half hour, says Boyle. The hospital designed the meetings to be quick and provide an overview of efforts that are under way.

Boyle cautions that not all best practices are applicable to every team.

"What works in pediatrics might not work for cardiac," she says.

The teams' ultimate purpose, though, is to make use of information from staff members who work with patients each day.

Giving staff members a voice allows them to take action, adds Carol DeJesus, LCSW, CCM, director of social work and care coordination at the facility.

Making change

The BRTs want to question the status quo and find more efficient ways to do things.

As a result, the teams have brought down some "sacred cows" within the organizations-things that weren't questioned in the past, says Boyle.

Ultimately, the BRTs at New York-Presbyterian have led to:

Reduced LOS
Increased communication between patient care providers
More efficient handoffs at discharge

The BRTs are also more engaged with the IT department, which provides team members with real-time data to analyze their efforts, says Boyle.

Using this data, the teams continually assess how well initiatives are working and take lessons from less-successful plans.

Putting the program into action

If you're looking to start a BRT program at your own facility, you must first gain the support of leadership. You must also understand that these groups are not a place to lay blame.

"The goal is not to go around pointing fingers and saying, 'You have to fix this,' " says DeJesus.

Remember to do the following when initiating a BRT program:

Keep meetings short. Meetings should be no longer than half an hour, and their agendas should be streamlined accordingly.
Don't fear failure. New York-Presbyterian learns from trial and error. If an initiative doesn't work, the organization moves on and finds one that does, says Boyle.
Listen to those on the front lines. Help your frontline staff share the information they gather daily. Putting this information into action will enable your organization to make strides toward improving how its systems work.

Future goals

Avoiding sticky legal issues during discharge

Explain legal issues that may be encountered during the discharge process
Avoid potential legal problems associated with patient discharges

Making sure patients are prepared for discharge can be a tricky process. When certain laws are considered, getting patients to their next destination becomes even more complex.

Understand legal documents. One of the most important roles of the social worker and case manager is to identify discharge barriers early. For example, a patient might be admitted for care but have no capacity to make decisions or to care for him or herself in the community. In such a case, the case manager and/or social worker should determine whether there are any legal documents identifying a person with authority to make decisions for the patient, says Alexandra Trinkoff, senior associate general counsel at the North Shore-LIJ Health System, based in Great Neck, N.Y.

"The legal relationship could be incorrectly interpreted if this step isn't taken," says Trinkoff.

For example, a patient might have paperwork showing that another individual has power of attorney. Often, though, the power of attorney only applies to financial decisions, not medical ones.

Establish guardianship. Whether you're trying to remove a guardian who isn't acting in the patient's best interests or getting the patient to accept a new guardian, you will often find yourself in prickly legal territory, says Trinkoff.

While it may be tempting to have a court sort through the mess, in general it's best to avoid dragging these cases into the legal system, says Trinkoff.

Also consider planning ahead to avoid trouble with guardianship issues during future visits.

Uphold patient rights. Case managers will sometimes run into situations where a patient wants to make a decision that is not in his or her best interest. For example, a homeless patient might want to be discharged back onto the street.

"As long as they have the capacity, they should be permitted to make that decision," says Trinkoff.

"Sometimes this might change the patient's mind," says Moore.

Provide patients with choices. Case managers should allow patients to choose their own postacute care facility or service. The government mandates that patients be given a choice of providers.

"Sometimes, choice is limited based on the patient's needs and/or the patient's insurance.

"However, we try to provide patients with the necessary resources so they are able to make an informed decision."

Overcome challenges related to undocumented individuals. Undocumented immigrant patients aren't typically eligible for government support services. Identifying these patients early is important, though, because there may be legal recourse to provide them with benefits, says Trinkoff.

Some nongovernmental groups, charities, or religious organizations might also offer services.

Ultimately, there may be many perils when it comes to discharge, but early intervention with patients can make a huge difference.

"Every single patient has their own challenges," says Trinkoff. "It's important to get them appropriate resources so that they can be well taken care of when they leave."

Take control to reduce the strain from audits

Analyze new audit responsibilities and their effect on case managers
Demonstrate new strategies to help streamline the audit process

Case managers have already become familiar with the Medicare Recovery Audit Program. In January, however, government Recovery Auditors began focusing on new territory: Medicaid claims.

The good news: The Medicaid audits are similar to Medicare audits, and case managers can prepare for them in the same way.

While you can't make these audits disappear, you can help manage them by contributing to your organization's Recovery Audit team and planning your new workload, says Stark.

Below are some tips to help you stay ahead of your audit-related responsibilities and thwart problems that may trigger audits:

Form a team. "The best way to prepare for the Recovery Audit, or any audit, is to begin by identifying who will be the lead in your institution and then establishing a strong collaboration between all the departments who will be involved in your hospital's RAC process," says Stark. An effective team includes representation from:
- Medical records
- Patient accounts
- Coding
- Admitting
- Compliance
- Case management
Consider your workload. Plan ahead to make sure you don't become overwhelmed by audits. Assess your department's staffing needs to determine whether you will need additional help with the increased workload, says Stark.

"Approximately 200 charts can be requested every eight weeks, indefinitely," says Stark. "So cases can be in multiple stages of the review and appeal at the same time for years."

Get ready to act quickly. If you receive a request for additional documentation, respond to the inquiry quickly, says Suzanne Lash, director of health information management at Fisher-Titus Medical Center in Norwalk, Ohio.

Focus on problem areas. Recovery Auditors often focus on specific areas where many organizations fumble. For example, auditors will likely target inpatient versus observation status assignments, says Lash. Take time to understand and assess the risk areas on which the Recovery Auditors focus.

Consider rebilling. If you find that you have billed incorrectly in the past, it's not too late to take action, says Lash. "If you think a claim is going to be denied, it may be worth trying to rebill it," she says. For example, if you believe a patient may not have qualified for an inpatient stay, you can rebill for services that would have been approved for an outpatient visit.

You may want to stick with newer cases for this strategy, but it may still be worth trying on the older ones, notes Lash.

Adjust your tactics. Due to Recovery Auditor scrutiny on issues such as medical necessity and inpatient versus observation status, case managers at Fisher-Titus Medical Center now target these areas. "We're redesigning our case management program so that we can have more focus on clinical documentation and the [utilization review] aspect of making sure patients are assigned the correct status," says Washburn.

The case managers determine what constitutes an observation stay and what constitutes an inpatient stay, but they also ensure that they have the documentation to back up the physician's decision.

"A patient may very well meet the criteria for an inpatient stay, but it isn't valid unless you have the documentation to go along with it," Washburn says.

Don't be afraid to appeal. Don't just accept the word of a Recovery Auditor without doing your own investigation. "We look at each issue and weigh it considering the cost versus the time it takes to appeal it," says Washburn. Many times appealing pays off.