The solution to getting patient status right is to have case managers in the right places to review the cases of patients who are coming into the hospital, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.
She recommends that hospitals place case managers in the emergency department seven days a week, at times when the volume is high. There also should be a case manager reviewing the cases of patients who come through other points of entry — patients who have had surgery and those who are admitted directly from a physician office or who are transferred from other hospitals.
Establishing the position of perioperative case manager to review surgical orders ahead of time and work with the physicians to get the patients’ status and orders right is one solution to ensuring that surgical patients who are admitted meet inpatient criteria, Cunningham says.
In smaller hospitals, the emergency department case manager could also review patients who are being directly admitted, she says. In a few large hospital systems, case managers work in the transfer center, she says.
When CMS issued the Two-Midnight rule, some people interpreted it to mean that medical necessity reviews no longer were needed and some hospitals eliminated the position of emergency department case manager or had them focus on discharge planning, says Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare, with headquarters in Chicago.
That was a big mistake, she adds.
“Hospitals have to have a case manager in the emergency department working with physicians to get patient status right on the front end so they don’t end up using Condition Code 44 frequently to correct patient status,” she says.
Sallee also recommends having case managers in the transfer center and other areas, such as the cardiac catheterization lab. “So many cardiac patients should be receiving observation services rather than being admitted. With cardiac catheterization patients, there is a fine line between when they meet criteria for an inpatient admission and when they should be receiving observation services,” she says.
In some cases, the decision to place patients in observation or to keep them there for an extended period depends on how difficult it is to get services scheduled, Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Services, a Shawnee, OK, healthcare consulting firm.
For instance, many hospitals don’t have the ability to perform cardiac stress tests on weekends and some cardiologists will not send a chest patient home until they have the results of a stress test, so the patient stays until Monday. Others are willing to consider scheduling the test for Monday and sending patients home if they are low risk.
“Stress tests and other services that aren’t available on weekends are problematic when it comes to justifying inpatient stays. The real answer is having the services available every day of the week, but that’s not practical for some hospitals,” Hale says.
