Designing the MOON Form and Process Was a Team Effort
Document meets requirements of state and CMS
When CMS announced the Medicare Outpatient Observation Notice (MOON), a multidisciplinary team at UCHC/John Dempsey Hospital in Farmington, CT, developed a form and a process that would meet the requirements of both the state of Connecticut and CMS.
Since 2014, the state of Connecticut requires hospitals to provide both written and oral notification to patients in observation for 24 hours or longer.
A team that included the utilization review committee, case managers, and representatives from the compliance department collaborated on the new form, says Mary Laucks, RN, CCM, senior director of specialty services at the 234-bed general medical and surgical academic medical center, part of UConn Health.
“The goal of the committee was to develop a form that we could give to all patients. We felt like if we added a form just for the Medicare patients to all the other paperwork the case managers deal with, we might miss someone,” Laucks says.
Case management representatives on the team included Laucks, the case management supervisor, and a staff case manager.
“Since the case managers on the floor are the ones who are going to fill out the form and deliver it, I thought it was important for a staff case manager to help design the form and the process for delivering it,” Laucks says. At John Dempsey Hospital, the case management staff deliver the MOON as well as the Important Message (IM) from Medicare and the Hospital-Issued Notices of Noncoverage (HINNs).
For the new form, the team took the language supplied by CMS and added an explanation of why the patient might not be at an inpatient level of care.
The committee developed a draft of the new form and passed it to committee members to review and add input. “We met twice but did a lot of emailing back and forth as we fine-tuned the form,” Laucks says.
When the team added information to the form, Laucks asked the hospital’s legal team to review it. “We wanted to make sure it was compliant since we added to the form so we could give it to non-Medicare patients as required by the state,” she says.
The document is printed on a two-part form with one copy for the patient and another for the medical record.
It was helpful for a staff case manager to be familiar with the MOON document when the new process began, Laucks says.
“We don’t have an embedded nurse educator in this department, so it’s a challenge to educate the staff when new laws and requirements are implemented. The case manager on the committee is on the floor every day with the other case management staff and helped the case management supervisor implement the MOON process,” Laucks says.
Before the MOON was required, the ED registrars helped get the IM signed and documented. But when delivery of the MOON was added to the mix, there were glitches, Laucks says.
“Before the MOON was implemented, we found that sometimes patients got the IM when they should have gotten an observation. We took a step back and involved the case managers to make sure patients get the right forms,” she says.
Both clinical nurse case managers and master’s prepared social worker case managers cover the ED for 16 hours a day on weekdays and 12 hours on weekends.
The ED case managers assess every patient who is admitted or receiving observation services. If they are placed in observation, the case manager gives the MOON at the bedside in the ED. Patients who are admitted to inpatient status receive the Important Message.
When patients are in the ED, the ED physician discusses the case with the attending physician. They decide the status, and the ED physician enters the status and other orders.
“We give patients the IM or the MOON as soon as their status is decided. Whenever possible, we try to give them the documents while they are still in the emergency departments. Since our emergency department physicians have admitting privileges, we can give the forms early — rather than waiting for patients to be transferred to the unit,” she says.
Each morning, the case managers on the floor review the hospital census and note whether the required forms have been given to patients. If a patient is due an IM or MOON, the case manager makes that the first priority. Observation patients are dispersed throughout the hospital.
The MOON form is available in English and Spanish. If patients speak another language, the case manager arranges an interpreter. “We have a robust translation program as well as some bilingual staff members. But we require all translators to be certified,” Laucks says.
When CMS announced the Medicare Outpatient Observation Notice, a multidisciplinary team at UCHC/John Dempsey Hospital in Farmington, CT, developed a form and a process that would meet the requirements of both the state of Connecticut and CMS.
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