Discharge Navigators Facilitate More Efficient Transitions
By Melinda Young
Skilled nursing facility (SNF) beds were limited in one hospital’s region, even before the COVID-19 pandemic decimated nursing home staffing across the United States.
“We are very challenged with skilled facility beds in our area,” says Amanda Hargrove, DNP, NE-BC, CMAC, ACM-RN, senior director of case management and utilization review at ECU Health in Greenville, NC. “At times, they’re delayed — not because of authorization, but because of lack of bed availability.”
For example, the hospital must send complex patients out of state if they need specialized SNF care. “We have some of the most complex patients, and they have needs that include ventilators, dialysis, and they have trachs,” Hargrove explains. “We have many patients who are greater than 350 and 400 pounds, and some are between 600 and 900 pounds. They are very complex patients, and there are not a lot of resources in our area to support the patients.”
If patients are admitted to the hospital and need a ventilator, trach, or dialysis, and they cannot be supported in the home environment, they have to go out of state for a SNF or other facility that can help them. “We send a lot of our patients to Maryland and to a few places in Kentucky,” Hargrove says.
Patients who weigh hundreds of pounds also are difficult for nursing facilities to handle, particularly when it comes to turning them to prevent pressure injuries. The bariatric population needs additional staff time, and most SNFs are short on staffing resources.
“Will they take on a patient who needs more resources to meet their needs?” Hargrove asks. “It’s very difficult to handle them.”
Even without that long-term problem of those kinds of complex needs patients, hospitals struggled with transitioning patients to SNFs since the COVID-19 pandemic began. ECU Health’s solution has been to assign a discharge navigator to work on obtaining authorizations for transferring patients to SNFs. Instead of waiting for the SNF to obtain authorization for a particular patient, the discharge navigator handles this task. Authorization turnaround times have been reduced from several days to several hours.
“We include patient’s choice, but from the very beginning we let patients know that we’re going to extend that search so they can make an informed decision about where they want to go,” Hargrove explains. “We want to make sure patients get the right care at the right time.”
When patients are medically ready to transition to a lower level of care, case managers will offer them options for SNFs. The discharge navigator will work to find an available SNF bed and obtain payer authorization for the transfer.
“Once we get a bed offer, we get authorization. At that point, if the patient has the bed and the authorization and is medically ready to transition, that’s where we would expect the patient to go,” Hargrove says.
The discharge navigator has reduced the time to obtain SNF authorization and improved hospital bed turnovers partly by anticipating insurers’ questions and preparing answers.
“When we submit clinical information to the insurance provider to approve for skilled nursing facility care, they come back and say, ‘I need more therapy notes,’ and ask for more information. That adds to the turnaround time for authorization,” Hargrove explains. “Because we have three team members who are really good at doing this, they give those payers what they need up front.”
Medicaid cases are especially tricky because it can take 45 to 90 days in North Carolina to obtain a SNF approval from Medicaid, Hargrove notes. This means patients will need to either stay in the hospital or be transferred to the SNF before Medicaid approval.
“We have a trusted network of skilled nursing facilities in our area, and we partner with them to contract for services if it’s a Medicaid-pending case,” Hargrove explains. “They can go to the skilled nursing facility, and when the patient is approved for Medicaid, it is retroactive back to the date when they went to the facility.”
Most of the time, Medicaid reimburses for that preauthorization care. “We have a good record on getting them approved,” Hargrove says.
The discharge navigators hold bachelor’s degrees in social work, and they work remotely. “They work with Medicare third-party payers so that we can submit that information and get that approval,” Hargrove says. “They also help manage our denials for SNFs.”
Managing denials is important. “We’re seeing an increased volume of denials for SNFs,” Hargrove says. “These team members have gotten very good at managing the denials process for appeals.”
“When we started the program, it was just for them to get authorization for the SNF,” Hargrove adds. “As we grew that program, they expanded their role to include processing denials that come for SNF admission.”
Initially, discharge navigators focused on Medicare Advantage plans. The program expanded to Medicaid managed plans and commercial plans. “Anytime we get a denial, it extends that length of stay, and we always make sure patients and families are aware of what’s going on,” Hargrove says. “We give them the information we received from the payer — that they denied the care.”
Then, patients and families often reach out to the payer to advocate for the discharge plan so the patient can obtain the right level of care at the right time. “We always have a back-up plan of connecting patients with services if they go home to the community,” Hargrove notes. “We have dual discharge planning because of the high number of denials.”
When patients are ineligible for SNF care, or when their transfer is denied, case managers perform a caregiver assessment that is incorporated into the discharge assessment, Hargrove says. The assessment questions include:
- Can the caregiver learn skills needed to take care of the patient?
- Does the caregiver work?
- Is the caregiver available 24/7?
- Is transportation available?
- Are they going to take the patient to follow-up appointments?
- What is the back-up plan if the caregiver is unavailable?
“It’s a tool we created, and it’s in our electronic health record,” Hargrove says. “We also assess the caregiver’s health and whether they are physically able to meet the needs of the patient.”
If the patient’s family can afford to hire personal care services, this could be a helpful part of their transition home. “If personal care is something they would be interested in, we connect them with a choice of agencies,” Hargrove explains. “If they need a skilled visit in the home, including therapy, they get that.”
Case managers need to empathize with patients and their families, but also find solutions that may have a family pulling together to provide multiple caregivers to help the patient. One person may help two or three days a week, and someone else helps on other days.
“We help them understand that this [transition to SNF] is not available because of your payer, but let’s work to get a plan and see what your resources are,” Hargrove says.
SNF beds were limited in one hospital’s region, even before the COVID-19 pandemic decimated nursing home staffing across the United States. ECU Health’s solution has been to assign a discharge navigator to work on obtaining authorizations for transferring patients to SNFs. Instead of waiting for the SNF to obtain authorization for a particular patient, the discharge navigator handles this task.
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