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The final rule for the fiscal 2013 Inpatient Prospective Payment System (IPPS), effective Oct. 1, 2012, continues the Centers for Medicare & Medicaid Services' (CMS) move to tie reimbursement to quality, rather than merely quantity, and makes it more important than ever for case managers to ensure that documentation in the medical record is complete and clearly reflects the patient's severity of illness, says Susan Wallace, MEd RHIA, CCS, CDIP, CCDS, director of compliance/inpatient consultant for Administrative Consultant Service, LLC, a healthcare consulting firm based in Shawnee, OK.
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These days, if hospitals don't have case managers in the emergency department, especially during peak hours, they run the risk of losing reimbursement as well as having their facility inundated with repeat users who don't have the resources to manage their healthcare in the community.
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Community Memorial Hospital's Intensive Case Management Program, which connects frequent emergency department users with appropriate community-based services, has decreased emergency department visits by 42% for a cost savings of $157,769, acute care admissions by 44%, saving $370,475, and reduced the average length of stay by 1.2 days for patients in the program at the 250-bed community hospital in Ventura, CA.
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Faced with a growing uninsured population, The MetroHealth System in Cleveland created an HMO-like system in 2010 to provide care for uninsured patients and embedded case managers in the health system's 11 clinics to ensure that uninsured patients get the care they need to avoid emergency department visits and hospitalization.
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The emergency department is evolving from being the gate of the hospital to being a front porch for the community, a central location where people with healthcare concerns can come and be triaged to the proper venue for care, says Karen Zander, RN, MS, CCMAC, FAAN, principal and co-owner of The Center for Case Management in Wellesley, MA.
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By collaborating on a case management program for uninsured and underinsured patients who overuse the emergency department, two hospitals in Lincoln, NE, have reduced the number of emergency department visits by patients in the program by 56% and cut emergency department costs related to non-emergent care by 67%. In 2011, the initiative saved the two hospitals about $700,000 in uncompensated care costs.
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In an effort to reduce readmissions, University Hospital in Newark, NJ, partnered with the Visiting Nurses Association Health Group and developed a program that uses intensive case management to reduce readmissions for patients with multiple chronic conditions.
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Every now and then at Sunnybrook Health Sciences in Toronto, Canada, there was talk about getting ventilated patients up and about even if they were still intubated.
