Accountable care units can help streamline communication and reduce length of stay
Learning objective
At the completion of this educational activity, the learner will be able to:
- Identify the potential advantages and challenges involved with establishing a hospitalist accountable care unit
Opening the lines of communication between clinicians and specialists to make care more efficient can be a sizable challenge.
At many facilities, hospitalists shuttle from floor to floor to see patients, each time trying to track down the nurse and other professionals working on each case. Information is typically transferred through an inefficient system of pages and phone calls?sometimes taking hours at a time to deliver crucial pieces of information.
Enter the accountable care unit?a new way of configuring care systems that can help to uncoil tangled communication wires between clinicians and support staff to provide care that is more efficient and streamlined.
In this model, hospitalists work with patients in a specified geographical area of the hospital in conjunction with interdisciplinary teams.
Having patients in one area helps make care more efficient, and as one hospital system in New Mexico learned, can also reduce length of stay and increase cost-efficiency.
A push toward regionalization
Regionalization of hospitalist patients is becoming more common today, because of the benefits it’s been shown to bring, says Stefani Daniels, RN, MSNA, ACM, CMAC, founder and managing partner of Phoenix Medical Management in Pompano Beach, Florida. Those benefits include:
- Improved teamwork, care coordination, and communication
- Fewer readmissions
- Improved resource management to lower cost of care
- Improvements in patient satisfaction
- Reduction in inefficiencies
"I’m pushing accountable care units at all my hospital clients," says Daniels. But while the will is there in many cases to make the change, it’s not always an easy conversion.
Sometimes these initiatives face pushback from physicians concerned about personnel or scheduling issues.
Other challenges include:
- The lack of diagnostic diversity that results from having set teams on a unit
- The challenge of deciding whether teams should be flexible or static
- Hammering out logistical issues, such as how patients should be triaged and how beds are managed
Despite the challenges these initiatives can face, Presbyterian Medical Group in Albuquerque, New Mexico successfully implemented a unit-based model with multidisciplinary rounds about six years ago, says David J. Yu, MD, MBA, FACP, SFHM, medical director of adult inpatient medicine service for Presbyterian Healthcare Services.
The initiative was prompted by a desire to improve inefficiencies and streamline care. "We basically needed to improve patient flow and communication," says Yu. "But we also realized it was a very large process because it involved almost every department, including case managers, physical therapy, nursing, and ancillary services."
To overcome that daunting multi-departmental challenge, officials enlisted the hospital’s Lean Six Sigma group to help coordinate the project.
Presbyterian sought to trade its outmoded care model for something more efficient; one that would improve communication and eliminate delays related to breakdowns in this area.
The changes began as a unit-based project with multidisciplinary whiteboard rounds, a daily meeting that included the hospitalist, nursing staff, care coordination, physical therapy, and other specialists. They discuss the treatment plan and the goals related to the patient care both for that day and the hospitalization for each patient, he says.
The success of that pilot program led officials to implement the same unit-based model in eight of the medical floors at the hospital.
The payoff for the organization has not only been a huge boost in the efficiency of communication, but reduced length of stay for patients. "We’ve seen significant improvements in the average length of stay. This is not because we’ve reduced therapeutic time, but because we’ve reduced inefficiencies," says Yu. Lag time created by communication gaps has been tightened up, allowing patients to move through the system more quickly and efficiently.
To ensure that these new efficiencies weren’t resulting in quality reductions, Yu says the organization also tracked readmissions, which remained steady, confirming that faster discharges weren’t compromising patient care.
Overcoming obstacles
Presbyterian has managed to overcome many hurdles that can make this model a challenge. Although these changes have been successful, they have not necessarily been quick.
"I think in many cases people are just interested in a quick fix," says Yu. This process has been anything but. More than half a decade in, Yu says the program is still a work in progress and the team is continually looking to make improvements.
The initiative took time because it addressed the underlying structure of the organization and didn’t just make surface changes that can’t be sustained.
"I like to use the analogy of painting a wall. The painting is the easiest part. What takes time is all the prep work getting the surface ready," he says.
Most organizations just want the paint on the wall?they aren’t willing to address work needed to fix the underlying structure. "This really is a foundational project that takes months and years to develop and mature," he says.
This project not only solved many communication problems at the organization, but it also helped to ready the facility for the new era in healthcare ahead?one where revenue is driven by quality, not volume.
Organizations that want to thrive in this new model will need to rethink antiquated processes and systems going forward, he says. Those that don’t may not survive in this model.
Steps to success
For an initiative like this one to be successful, it has to be well designed and have support?both in commitment and in terms of dollars?from upper management.
"A lack of resources is another reason why a lot of these projects fail," says Yu. "The hospital doesn’t want to fund it. If only one department is very excited about the project, it won’t work."
The model involves a major change that requires support from multiple disciplines. "Without the support of leadership it’s not going to succeed," he says.
You also have to give hospital staff members a reason to support it, which may be the biggest challenge.
"It has to successfully answer the question, ‘What’s in it for me?’ " says Yu.
If the changes are onerous and provide little benefit to the people they affect, there’s little incentive for anyone to support it.
"Understand your worker and your project," he says. And overcoming barriers may involve system and even contract changes, he says.
If you can get that support, you can make changes that will improve communication and consequently care at your organization?and help ready it for the changing healthcare landscape of the future.
Commonwealth Fund study shows insurance gaps remain
Learning objective
At the completion of this educational activity, the learner will be able to:
- Identify potential risk factors and interventions for patients who still don’t have health insurance under the Affordable Care Act
While some 26 million Americans have gained insurance since the Affordable Care Act (ACA) became effective in 2010, another 24 million U.S. adults are still living without coverage, according to a new report by the Commonwealth Fund, a private, nonprofit organization that supports health policy research and reform.
This is a concern because not only are uninsured adults likely to skip needed health services due to the cost, but a lack of insurance is also a risk factor for preventable hospitalizations and health declines due to chronic diseases, according to the Henry J. Kaiser Family Foundation (http://ow.ly/Bs3a304bJR7).
So who are these uninsured Americans? According to The Commonwealth Fund survey (http://ow.ly/I8uZ304cB2b), 88% are Latinos under the age of 35 who earn less than $ 16,243 and/or work for a small business. "Half (51%) of the remaining uninsured live in one of the 20 states that had not yet expanded Medicaid at the time of the survey," states a press release issued by the Commonwealth Fund (http://ow.ly/gqsB304bJZk).
Case managers should take note of the survey findings.
"The Commonwealth Fund analysis is beneficial to all case managers, because the uninsured population compromises our most at high-risk groups of patients," says June Stark, RN, BSN, Med, director of care coordination at St. Elizabeth’s Medical Center in Boston. "Most hospitals today seem to be the primary source of healthcare provision to the patients in their communities. Expanding the case manager’s understanding of this population can contribute to the development of successful strategies for managing this group."
About the study
The study, called The Commonwealth Fund Affordable Care Act Tracking Survey, consisted of 15-minute telephone interviews. Interviewers conducted the interviews in two languages, either English or Spanish, between February and April 2016. The data was collected by calling a random, nationally representative sample of nearly 5,000 adults ages 19?64.
Since the ACA went into effect, the uninsured population shifted from mostly white adults to Latinos, according to the Commonwealth Fund press release. Results also show that renewed efforts to help uninsured individuals gain coverage might also be in order.
"The ACA held promise for many, especially those with incomes that could bear new market sticker prices, and as can be seen from the study, diverse populations benefitted from targeted reform marketing efforts," says Shawna Grossman Kates, MSW, MBA, LSW, CMA, the director of case management and bed management for RWJBarnabas Health in Toms River, New Jersey. "Yet it is very apparent that while there has been success with some at-risk populations, those with the lowest incomes who do not qualify for Medicaid are still struggling."
This study, she says, shows it may be time for a revival of the initial efforts to enroll Americans in health plans, which have become less prominent over time. There may also be a role for case managers and social workers to help guide uninsured patients they encounter in the hospital to seek coverage.
"The case manager has an active role in helping patients acquire insurance coverage," says Stark. "A mainstay of the traditional case manager role is, during the admission assessment, to determine if the patient has insurance and if so, to validate if it is correct and active. This is accomplished by interviewing the patient, viewing their insurance card, and checking further with the help of the hospital’s financial counselors."
If a patient is uninsured, case managers should refer him or her to financial counselors to determine the patient’s eligibility and to help him or her secure insurance during the hospital stay, she adds.
"The case manager’s efforts to secure insurance is essential, as the specific insurance benefits drive what discharge options are available for the patient, and therefore, helps secure a safe discharge plan," says Stark.
Social workers, too, play a role.
"It is often the social work partner in a case management relationship who provides the under-insured and uninsured the counseling, available tools and resources, and sometimes the hands-on, step-by-step training to explore with patients and families their income/assets/spending and eligibility for entitlement programs or market products," says Kates. "It is a continuous conversation that has been rooted in a long history of patient intervention by social work. Possessing expert knowledge in federal and state eligibility requirements, financial/social access limits, and having strong relationships with county and state providers, the social worker will connect services with patients."
In their role as patient advocates, case managers and social workers can help to break down cultural and social barriers, such as language and access based on geography, she adds.
Action points from the Commonwealth Fund
The Commonwealth Fund study authors agree with Kates that enhancing efforts to reach the uninsured and help them enroll in health plans should be a goal based on these findings. Only 62% of people without insurance said they knew about insurance marketplaces.
They also recommend a number of other steps that they say could help more of these uninsured individuals gain coverage. Their recommendations are as follows:
- Expand state eligibility for Medicare coverage, a move that Commonwealth Fund authors say would "immediately extend health insurance to millions of uninsured people." Twenty states had not yet expanded Medicaid coverage at the time of the survey. If they had, one-third of all adults without insurance would qualify for Medicaid coverage. "This especially affects uninsured young adults, of whom 38% or an estimated 4 million, have incomes that would qualify them for Medicaid but live in non-expansion states," states the press release.
- Enhance subsidies and lower cost-sharing in marketplace plans to help more people afford insurance. Many people without insurance believe they can’t afford it?even if they might qualify for financial help under the ACA. Some 85% of those without insurance who did shop for a plan said they couldn’t find an affordable option. "A large majority of this group, who were also uninsured, had incomes qualifying them for subsidies or Medicaid, though some may not have been eligible due to their immigration status," states the press release.
- Promote immigration reform. Changing immigration rules would help more people gain insurance coverage. "A loosening of the law’s restrictions on eligibility for undocumented immigrants would also help," states the Commonwealth Fund press release. While the survey data didn’t definitely prove that this is the case, study authors suspect that many Latinos lack insurance coverage because they may be undocumented and not eligible for coverage under the ACA. Other risk factors that may also be at play: Latinos make up nearly half of adults who are earning less than 138% of the poverty level?$ 16,243 for one person or $ 33,465 for a family of four.
Ultimately, using a combination of local and federal interventions can help the U.S. move closer to its goal of helping get coverage for all its citizens.
Is the 2-midnight rule going away and when will short-stay audits resume?
Learning objective
At the completion of this educational activity, the learner will be able to:
- Identify updates to CMS’ 2-midnight rule and best practices for compliance.
Every couple months, it seems questions arise about the 2-midnight rule and there are rumors that it may be going away. Below are some questions with answers from our expert Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago, to clarify where things stand today with regard to the 2-midnight rule.
Q: I heard the 2-midnight rule is now gone based on changes to Medicare payment rates under the 2017 inpatient prospective payment system (IPPS) final rule. Is this true, and if not, what changed?
A: No, this is not the case. The 2-midnight rule is still alive and kicking. What the FY 2017 IPPS final rule did is finalize two adjustments in addition to updating the annual rate for inpatient hospital payments.
"First, CMS is finalizing the last year of recoupment adjustments required by the American Taxpayer Relief Act of 2012 (ATRA). Section 631 of ATRA requires CMS to recover $ 11 billion by FY 2017 to fully recoup documentation and coding overpayments related to the transition to the MS-DRGs that began in FY 2008," states the CMS Fact Sheet. "For FYs 2014, 2015, and 2016, CMS implemented a series of cumulative -0.8 percent adjustments. For FY 2017, CMS calculates that $ 5.05 billion of the $ 11 billion requirement remains to be addressed. Therefore, CMS is finalizing a -1.5 percent adjustment to complete the statutorily specified recoupment."
And the second part of the change, which seems to be causing the confusion, is CMS took action on a -0.2 percent adjustment it implemented in the FY 2014 IPPS final rule.
This adjustment was initially made to account for an estimated increase in Medicare spending due to the 2-midnight policy. "Specifically, in the FY 2014 IPPS final rule, CMS estimated that this policy would increase expenditures and accordingly made an adjustment of -0.2% to the payment rates," states the fact sheet.
While CMS thought this adjustment was reasonable at the time, a recent review led CMS to permanently remove this adjustment, "and its effects for FYs 2014, 2015, and 2016 by adjusting the 2017 payment rates. This will increase FY 2017 payments by approximately 0.8%," stated CMS.
Hirsch says this move is "purely about money." "They are leaving the 2-midnight rule itself completely intact," he says.
The bottom line: Pay attention to 2-midnight compliance and ensure your organization has good systems in place to support it.
Q: When are Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO) short-stay reviews going to resume?
A: Back in May, CMS put a hold on short-stay inpatient audits related to the 2-midnight rule. That hold was lifted effective September 12, 2016, according to a FAQ published by CMS (http://ow.ly/DQxW304bCa6).
According to the FAQ, CMS decided to lift this temporary suspension for five reasons, which are as follows:
- BFCC-QIOs were successfully retrained on 2-midnight rule
- BFCC-QIOs finished a re-review of claims that were formally denied
- CMS "examined and validated the BFCC-QIOs peer review activities related to short-stay reviews"
- BFCC-QIOs reached out to providers on claims that were affected by the temporary suspension
- BFCC-QIOs started provider outreach and education on the 2-midnight rule
It appears that based on the five points, the temporary audit suspension accomplished its goal of helping BFCC-QIOs sort out the challenges they faced during the initial round of audits.
Prior to the suspension, hospitals complained about inconsistencies in the review process, which triggered the suspension. The BFCC-QIO audits began in October 2015, and hospitals reported a number of surprises including:
- Auditors requested records as far back as May 2015 when many believed the audits would only look at records from 2015 forward
- BFCC-QIOs missed deadlines, and provided audit results late
- Failure by BFCC-QIOs to schedule timely education for providers
These problems made it difficult for hospitals to hit filing deadlines, and they were consequently reporting problems because they missed the window to appeal denied claims. Hospitals also didn’t have a chance to get education to understand what they were doing wrong to fix the problem.
There were also rumored problems related to benchmark admissions. Hospitals reported that BFCC-QIOs were routinely and in some cases inappropriately denying inpatient admissions when the patient spent one night as an outpatient in the emergency department or in observation services before he or she was admitted?even when the patient spent a second night in the hospital as an inpatient.
To prevent future problems, CMS said in its FAQ that it will continue to provide oversight for BFCC-QIO efforts by:
- Reviewing a sample of completed claim reviews each month
- Monitoring provider education calls
- Responding to individual provider inquiries and concern. Providers may send questions to the CMS Open Door Forum Mailbox at ODF@cms.hhs.gov.
CMS also said that BFCC-QIOs will continue tofollow the guidance called, "Reviewing Short-Stay Hospital Claims for Patient Status." To see a copy ofthe guidance, go to www.cms.gov/research-statistics- data-and-systems/monitoring-programs/medicare-ffs- compliance-programs/medical-review/inpatienthospitalreviews.html.
The BFCC-QIOs will also be charged with providing provider education going forward. "The BFCC-QIOs were directed to use comprehensive outreach and communication approaches (i.e., website, newsletter, one-on-one training, and town hall type events) to continue to educate providers on when payment under Medicare Part A is appropriate under the 2-midnight policy," states the FAQ. "BFCC-QIOs are required to educate providers using quality improvement core principles that facilitate continuous learning and promote greater provider understanding of the appropriate application of the 2-midnight policy in accordance with the revisions in the CY 2016 OPPS Final Rule (CMS-1633-FC): www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1633-FC.html."
Now that audits have resumed, organizations should maintain a focus on 2-midnight compliance. Below are some tips Hirsch has recommended in the past, including:
- Reviewing every short-stay admission?those between zero and one day?prior to billing.
- Ensuring that every patient’s status is appropriate up front. Reviewing the chart of every patient that goes upstairs.
- Using the physician advisor to check compliance on cases that are murky to ensure that they meet one of the exceptions under the 2-midnight rule. Changing cases that don’t meet an exception using condition code 44. If the problem isn’t discovered until after discharge, self-deny and rebill the claim.
- Ensuring that the case managers and the physicians are up to date about any potential changes to the 2-midnight rule and how to comply.