Case Management Flashcards
ACMA
What does CoP stand for and what is it?
Conditions of Participation.
Clear requirements set by CMS for assessment and discharge planning.
Initial discharge assessment done on admission day. When should CM review patient and plan again?
Day 2
(the answer is NOT daily)
what are 3 functions of Utilization management?
1- risk management
2- eval of medical necessity
3- contributing to decreased denials
patient has been in observation status for 2 days and now ready for discharge to SNF. What is CM next action?
inform patient and family they may need to pay privately
Traditional Medicare: scenario- Patient has been hospitalized for one observation midnight, will discharge tomorrow. care needs are SNF placement. what is CM action?
Advise patient and family that Medical won’t cover SNF. Explore home discharge with home health /care giver support.
Which regulatory agency impacts case management functions?
Office of Inspector General
Readmission risk assessment may be built into the ongoing reassessment. There are several common tools for this assessment.
Name
1) Society for Hospital Medicine’s Risk Assessment: Project Boost Screening Tool, 8P
2) Boston University School of Medicine the Agency for Healthcare
Research and Quality (AHRQ) Project Red Toolkit (Re-Engineered Discharge).
3) Validated Risk Assessment Tool: the LACE Index scoring tool
What are all of these screening tools for?
Project Boost Screening Tool, 8P
Project Red Toolkit
LACE Index scoring tool
Readmission Risk Assessment tools
How long can observation be? according to medicare
Medicare allows observation status for up to 48 hours. Allows time for decision to either discharge or admit to inpatient.
There is a certification requirement at day 20 for long stay patients and cost outlier cases, and hospitals should have a process in place to ensure documentation of this certification is present. It must include: (5 things)
1) A signed inpatient admission order before discharge is required.
2) An adequate written record of the reason for either continued stay of the patient for medical reasons or special or unusual services for cost outlier cases.
3)The estimated period of time the patient will need to remain in the hospital or, for cost outlier cases, the period of time the special or unusual services will be required.
4) Any plans for post-acute hospital care.
5) If the patient is only in the hospital awaiting SNF placement, the physician progress notes must indicate that as the reason for the continued stay.
Important that hospital notify physician when patient approaches day_____.
day 20 - certification requirements for documentation
Level of care assignment is based on clinical condition and/or procedure. inpatient vs outpatient.
What are the 2 most used tools to help make this decision?
InterQual
Milliman Care Guidelines (MCG)
If there’s a disagreement between the criteria for level of care and the admitting providers decision, what happens next?
CMS CoP require hospitals to have a utilization management committee and a UM plan which outline process for secondary physician review.
What is Condition Code 44?
billing code used when it is determined that a traditional Medicare patient does not meet medical necessity for an inpatient admission. An order to change the patient status from Inpatient to Observation MUST occur PRIOR TO DISCHARGE.
what are 4 requirements that must be met to bill a Condition Code 44?
1-The change from inpatient to observation must be made prior to discharge.
2- A claim has not already been submitted.
3- The provider concurs with the UR committee’s decision.
4-Physician concurrence is documented in the medical record.
What if all 4 requirements are NOT met to bill a Condition Code 44?
the hospital may bill for Medicare Part B only
services.
Condition Code 44 situations apply only to patients with all Medicare
three broad objectives related to the case management planning process:
1)Collaborate with patient, family, clinical team and post-acute providers to determine goals and outcomes for patient.
2) Sequence steps and interventions to ensure timely completion of plan of care: Plan for the day.
Plan for the stay. Plan for the way to discharge.
3)Communicate plan of care to patient, clinical team and next-level providers.
Acronym offered by AHRQ to talk about Discharge planning
IDEAL
What is IDEAL and what does it stand for?
Discharge planning
I- Include patient and caregiver in goal setting for return home or next level of care.
D- Discuss Key areas for preventing problems after discharge ( meds, ADL changes, need for services at home.
E- Educate patient/ caregiver
A- Assess how all members of care team are explaining dx, tests, expectations, and next steps in plan of care. Consistency is critical.
L- Listen to patient/ caregiver goals for discharge, care, recovery.
Case Managers should be aware of the following quality measures and tools and their role in engaging and assisting patients in the decision-making process concerning care plan options: 2-
1- The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act)
2-CMS Five-Star Quality Rating System. This is a quality initiative that consists of a tool to help compare Skilled Nursing Facilities (nursing homes).
What is IMPACT?
Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) is a quality initiative requiring the reporting of standardized patient assessment data by post-acute providers
including Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities (SNFs), Home Health Agencies
(HHA), and Inpatient Rehabilitation Facilities (IRFs). The IMPACT Act supports the goals/priorities outlined
within these strategies, and overall helps to facilitate coordinated care, improved outcomes, and quality
comparisons for post-acute providers.
To support the goal of the IMPACT Act, CMS has launched Compare Sites for both IRF (IRF COMPARE) and LTCH facilities (LTACH COMPARE) to provide
public reporting of this quality data.
Case Managers should educate patients on the existence of these sites so they can compare data from various facilities in order to find an option that aligns with their preferences. The availability of this information facilitates informed decision-making related to transitions and allows patients and their families to be active participants in the planning process.
what is the CMS Five-Star Quality Rating System.
This is a quality initiative that consists of a tool to help compare Skilled Nursing Facilities (nursing homes). Case managers should educate patients on the availability of Nursing Home Compare as a tool that can be used to provide additional information on Health Inspections, Staffing, and Quality Measures in comparing facilities. Patients, families, and caregivers should be advised that this is a tool to supplement the decision-making process and should be used in conjunction with other sources of information, such as site visits.
Phrase that describes Planning and Intervention Sequence Steps and Intervene to Ensure Timely Completion of Plan of Care:
Plan for the day.
Plan for the stay.
Plan for the way (to discharge)
Plan for the day:
Planning for a patients day in the hospital begins with assessment to ensure the appropriate level of care. Initiating services at the right level of care is imperative to setting the patient on the correct path for evaluation, treatment and recovery.
The course of the hospital stay, in terms of resource use, patient experience and insurance payment, hinges on this initial determination being accurate. A mismatch between level of care and patient medical necessity and/or clinical condition disrupts planning in a number of ways, suchas: Delaying initiation of treatment, Adding unnecessary inpatient time waiting for consults or testing that
could be safely and appropriately performed in the outpatient setting, orManaging expectations that the
intensive care unit is appropriate for managing a patient who would be better cared for in a hospice or
palliative care setting.
Plan for the stay:
Anticipating and setting a target for the stay, or duration of
hospitalization, requires the case manager to understand the clinical condition, medical necessity and expected length of time it should take to complete the workup and provide the hospital phase of treatment.
This planning happens early in the admission, if not during preadmission. At this time, begin setting expectations for the patient and family, in terms of length of stay and expected day and time for
discharge, with the understanding that all target dates are anticipated and dependent upon patient
progress. Outlining these expectations is helpful for the patient, family and care team to provide a clear timeline to mark progress and an end point for hospitalization. Although each patients experience and plan of care should be individualized, most medical conditions and reasons for hospitalization fall within expected parameters for diagnosis, treatment and length of stay, and these expectations should be shared with patient and family at the earliest possible point. Patient conditions, however, may take unexpected
clinical turns, or may be highly complex due to trauma or underlying diseases. In these cases, the patient may not follow the generally expected path for hospitalization. The care team, as well as the patient and family, should review and revise the plan of care accordingly with frequent updates provided to the entire
care team. The level of care within the hospital, or the plan for testing or treatment, may need to be accelerated or altered, in order to address the change in condition in a timely manner.
Plan for the Way (of discharge):
The transition through and from the hospital includes the discharge plan and requires knowledge essential to development of effective planning, including the:
Full continuum of services beyond the hospital setting,
Eligibility criteria,
Likelihood that the patient’s insurance will
provide coverage, and
Patient’s level of engagement in helping to select the post-hospital care provider.
The post-hospital level of care requires an appropriate match between services and a patient’s clinical, functional and behavioral needs, as well as financial resources and insurance coverage. A patient’s clinical condition is the first factor driving the progression through the hospital and to the post-acute level of care.
What 4 questions can help a CM guide their efforts?
(according to NYU Langone Medical Center)
1- Why is the patient hospitalized?
2- why is the patient STILL hospitalized?
3- What has to happen for patient to safely leave hospital?
4- Where will patient be discharged to SAFELY?
There are four basic principles of healthcare ethics that should be practiced when
delivering healthcare services: autonomy, beneficence, non-maleficence and justice
autonomy, beneficence, non-maleficence and justice
The term non-maleficence refers to
doing no harm and is yet another of the four basic
ethical principles.
Ensuring that they receive treatment with human dignity and respect is one incredibly
important way to protect them. Proper management of pain, respect for privacy and attending to spiritual
needs are examples that may fall within this domain
Beneficence
When weighing options, the case manager and interdisciplinary team
generally focus on the benefits, weighing risks versus benefits in the attempt to do what is best for the
patient.
Justice
Fairness- access to needed high quality services may be limited due to financial or other barriers. Learning how to navigate or advocate for patient is important role.
The Patient Self-Determination Act (PSDA)
federally mandated law from 1990 that
requires hospitals and health systems participating in
Medicare/Medicaid programs to inform patients of their right to self-determination in healthcare decisions. The federal law requires that decisional patients be informed of their right to execute advance directives such as a living will or durable power of attorney for healthcare.
The law also specifies that the patient may not be discriminated against regardless of their
particular healthcare decision, including the decision to accept or reject treatment or care.”
The Uniform Health Care Decisions Act (HCDA)
enacted in 2000 to uniformly address, across all states, who could act on behalf of an individual who lacks legal capacity and a clearly executed advance directive/healthcare power of attorney.
For parents of minor children and legally appointed guardians, the courts clearly delineate the line of authority that can be relied upon by healthcare providers.
For patients that had not formally appointed a healthcare proxy, and who lack the ability or capacity to do so, this law provides for a uniform approach to determining who could step in and act on behalf of, and in the best interest of, the patient
The Uniform Health Care Decisions Act (HCDA)provides for a priority list of those who are eligible, such as first the spouse, second an adult child, third a parent, fourth a sibling, etc. Thus, according to the HCDA, the line of
authority follows specified sources for healthcare decision-making:
1-The individual patient with decision-making capacity.
2- The patient designated health care power of attorney.
3-A court-appointed guardian, or a surrogate/proxy decision-maker (based on the priority list).
Difference between capacity and competence
Competence is a legal term and a determination made by a judge in a court of law.
Patient decision-making capacity within the healthcare setting refers to a patient’s ability to
make independent decisions about his/her healthcare treatment.
More about this:
Capacity in this regard generally includes
the patients ability to:
-Understand the information being disclosed, including the risks, benefits and alternatives.
-Weigh the consequences and evaluate the impact of the decision on his or her life.
-State his or her choice and do so consistently over time.
Decision making capacity is situation specific. For
example, a patient may be able to make a decision about what type of medical treatment he/she wishes to have or understand the consequences of not accepting a particular treatment. This same patient, however, may not have the capacity to manage his or her financial affairs.
The Emergency Medical Treatment and Active Labor Law (EMTALA)
federal law passed in 1986 that applies to hospitals participating in Medicare and Medicaid programs.
Under this law, hospitals are required to provide emergency healthcare treatment to all individuals who present themselves to a hospital emergency department, regardless of their ability to pay or citizenship status. The care rendered must include an appropriate medical screening examination, and if an
emergency medical condition is identified, the patient must be treated and stabilized, or if safe and
appropriate or patient requests, the patient may be transferred.The transfer of unstable
individuals to another medical facility can only occur if a physician certifies that the medical benefits
outweigh the risks, or the patient requests the transfer in writing after being informed of the obligations under EMTALA and risks.
CoP-
What does CoP stand for?
Conditions of Participation
Describe CoP
To qualify for Medicare certification, health providers/systems must comply with a
minimum set of health and safety standards termed Conditions of Participation? (CoPs).
CoPs outline a broad range of standards including those for:
Utilization management.
Discharge and transition planning processes that apply to all patients.
A single standard of care/care planning process applicable to all patients.
Processes to address pain management.
Processes to ensure patient confidentiality.
Patient rights (which include rights to execute advance directives, informed consent, participate in plan of care and discharge plan or rights to choose post-acute care providers, such as HHC or SNF).
Important Message from Medicare (IMM) letter
CMS requires that all Medicare patients, upon admission (or within 2-days of admission)
to the hospital, receive an Important Message from Medicare (IMM) letter.
If hospital discharge occurs after the first 2-days, a second IMM is required to be given between 2-days of discharge, but not later than 4-hours prior to discharge.
This is to ensure that the patient is aware of the rights related to discharge appeal and is fully informed of the plan for discharge. If the patient, family, or even physician, do not agree with the plan and timing for discharge, they may follow the CMS process for discharge appeal.
Detailed Notice of Discharge
For patients or families who disagree with the plan and time for discharge and wish to appeal, a Detailed Notice of Discharge will be issued to the patient.
If the patient proceeds with filing an appeal with the hospitals regional CMS Quality Improvement Organization/Independent Peer Review
Organization (QIO/IPRO) and their appeal is overturned (i.e., the patient does not win his/her appeal), a Hospital Issued Notice of Non-Coverage (HINN) is issued. This essentially means that a patient no longer meets medical necessity for the continued hospital stay, and a safe plan for discharge has been identified.
All notices must be communicated both orally and in writing. Notices should also be documented in the
chart.
Hospital Issued Notice of Non-Coverage (HINN)
If the patient proceeds with filing an appeal with the hospitals regional CMS Quality Improvement Organization/Independent Peer Review
Organization (QIO/IPRO) and their appeal is overturned (i.e., the patient does not win his/her appeal), a Hospital Issued Notice of Non-Coverage (HINN) is issued. This essentially means that a patient no longer meets medical necessity for the continued hospital stay, and a safe plan for discharge has been identified.
All notices must be communicated both orally and in writing. Notices should also be documented in the
chart.
Medicare Outpatient Observation Notice (MOON)
standardized notice of status used to explain to Medicare beneficiaries their status as an outpatient in observation, not an inpatient. It includes an explanation as to why the patient is not inpatient and the implications of observations services related to cost-sharing and SNF coverage.
This is not a notice of non-coverage and must be received within 36 hours of the 24 hours of observation services.
An oral explanation is also
required when delivering the MOON notice and hospitals must maintain a signed copy
three options for the patient to choose relative to the ABN
- To proceed with care, have Medicare billed and if denied, appeal to Medicare
- To proceed with care and pay privately
- To forego the service
what’s wrong with last minute delivery of ABN?
Last minute delivery of an ABN can be construed as coercion. Last minute delivery is defined as, “after the beneficiary is likely to feel that the service has already begun and they have no
choice but to continue the service.”
For example, the beneficiary may have been connected to testing equipment or may have been placed in a testing machine (CAT scan).
Negotiating and Advocating for Patient Services and Resources Case managers have an
important role within the hospital/healthcare system and a responsibility to their patients to:
1-Manage and navigate the hospital/healthcare system on behalf of the patient for the protection of their rights, safety and health. Hospitals and health systems can give the impression of foreign, fragmented and unfriendly places for patients and their families/caregivers. At a time when patient and caregiver should be focused solely on getting through the current health crisis and moving towards recovery and wellness or transition to rehabilitation or palliation, they are oftentimes met with a barrage of clinicians they have never before met, confusing medical terminology, worrisome costs, impossible insurance battles and a setting that seems light years away from a healing environment.
2-Negotiate with payers, post-acute providers, internal providers and others to secure the needed services and benefits on behalf of the patient. This includes knowing facts, organizing arguments, analyzing how cost of benefit outweighs cost of potential readmission, as well as preparing for counterpoints and compromise.
3-Represent the patients voice when
the patient faces barriers to speaking up for him or herself speak up for what the patient wishes. This is
especially important for patients facing life limiting illness.
4-Help identify and/or secure the appropriate
surrogate decision-maker when the patient is unable to demonstrate decision-making capacity.
5- Assess for biases- your own, those of the care team, those of the patient/family - and then support the patients values and choices within a context of informed consent/informed decision-making.
Develop community agency collaboration to smooth care transitions, develop innovative approaches to complex patient discharges and to ensure bidirectional communication.
Awareness of proactive strategies is needed on the part of the case manager to stay ahead of
the risk posed by Recovery Auditors (generally referred to as RAC) and Medical Administrative
Contractors (MACs).
RAC and MACs represent reimbursement recovery arms of CMS. In particular, the rules and guidelines which apply to medical necessity for observation status, acute care admission and continued hospital stay can be difficult for the interdisciplinary team to determine or attend to. The financial risk to the hospital, and potentially to the patient, can be substantial if an admission or continued
stay is not properly managed in the eyes of CMS.
ACMAs official definition of case management, as approved by membership in November 2002, is as follows:
Case Management in Hospital/Health Care Systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and community.
The Case Management process encompasses communication and facilitates care along a
continuum through effective resource coordination. The goals of Case Management include the
achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patients right to self-determination.
Condition of Participation: Utilization Review:
states the hospital must have in effect a
Utilization Management Plan (UM Plan) that provides for review of services furnished by the institution
and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid
programs
SMART goals
Specific -simply written and clearly
defined
Measurable- tangible result that demonstrates the goal was achieved
Achievable- attainable, agreed upon, adequate resources
Relevan- is the goal worthwhile and aligned with other goals
Time-bound - timeframe is realistic yet creates a sense of urgency
Three principles for change management are:
Create a shared need for the
change.
Understand and deal with resistance from stakeholders.
Build an effective influence strategy and
communication plan for the change
Advance Directive:
Instructions given by individuals specifying what actions should be taken for their health in the event they are no longer able to make decisions on their own behalf.
Examples include:
Living Will: one form of an advance directive that leaves instructions for treatment.
Power of Attorney/Health Care Proxy: someone appointed by the individual to make decisions
on his or her behalf when he or she is incapacitated. Individuals may also have a combination of both
documents, which is often encouraged to provide the most comprehensive guidance regarding a patient’s
care.
Acute Inpatient Rehabilitation (AIR):
Acute Inpatient Rehabilitation (AIR):Level of care where patients must have had a recent
event altering functional abilities, have the strength and endurance to participate in three hours of therapy per day and have the cognitive abilities to learn progressively.
Assent:
To agree or concur. Used with regard to a minor making healthcare decisions.
Minors do not have a legal right to consent to healthcare treatment and require parents or guardians to do so on their behalf. However, a knowledgeable, mature minor may have the ability to understand his/her treatment risks, options, choices, prognosis, etc. and participate in the decision-making process by offering agreement with recommendations or “assent”
Beneficence
is action that is done for the benefit of others, or a group of norms pertaining to relieving, lessening, or preventing harm and providing benefits and balancing benefits against risks and costs
Capacity
Within the healthcare setting, this term refers to a patient’s ability to make independent decisions about his/her healthcare treatment. Capacity in this regard generally includes the patients ability to:
-Understand the information being disclosed, including the risks, benefits and
alternatives.
-Express the decision, and to do so consistently over time.
-Weigh the consequences and evaluate the impact of the decision at-hand.
Case Mix Index (CMI):
A hospital measurement representing the average
diagnosis-related group (DRG) relative weight for a given facility.
The CMI is calculated by summing the
DRG weights for all Medicare discharges and dividing by the number of discharges.
Competence:
A cluster of related abilities, commitments, knowledge and skills that enable
a person to act effectively in a variety of situations. Competence is also a legal term and a determination
made by a judge in a court of law. Decision-making capacity is not the same as competence.
Condition Code 44 (CC 44):
A code describing a change in status when specific criteria are met. Under hospital Conditions of Participation (COPs), Medicare requires that all hospitals conduct utilization reviews (UR) to ensure that all requirements are met. When the hospital UR committee reviews the case and, in consultation with the admitting or treating practitioner, determines the admission is not medically necessary, however observation services are appropriate, the admission may be changed from inpatient to outpatient status. This is called Condition Code 44.
The change is permissible if all of the
following conditions are met:
-The change in patient status from inpatient to outpatient (observation) is made prior to discharge or release while the member is still a patient of the hospital.”
-The hospital has not submitted a claim for inpatient admission
-A physician concurs with the
utilization review committee’s decision.
-The physician and utilization review committee’s decision is documented in the patient’s medical record. The medical record should contain orders and notes that indicate why the change was made, the care that was furnished to the patient and the participants making this decision to change the status. The patient must be informed of this change in status.
Conditions of Participation (CoP)
Sections of the Code of Federal Regulations that pertain to health and safety standards that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and for protecting the health and safety of beneficiaries.
There are two sections of CoPs particularly important to Case Managers - Utilization Review and Discharge Planning.
CoPs can also be the basis for other best practice standards, such as The Joint Commission
Detailed Notice of Discharge (DND Notice):
Provides a full explanation of the reasons for
hospital discharge and/or why services received are no longer covered by Medicare.
Diagnosis-Related Groups (DRGs):
A patient classification system used to identify
resources expended for hospital services without taking into account the therapeutic approaches
employed. In the DRG system, patient records are categorized into homogenous groups according to the diagnosis and healthcare expenses involved. The DRG system uses the following data for hospital
performance evaluation: average length of stay, average patient load, comparative performance index and case mix index
Extended Stay/Recovery:
Terminology used for outpatients in a bed who do not meet either Inpatient or Observation status requirements. These patients may be boarding after an uncomplicated procedure, or this classification is also used for social admissions. Generally, room and
board charges are not billable
HH face to face must occur how long before or how long after start of car?
The face-to-face encounter must occur within the 90 days prior to the start of home healthcare, or within the 30 days after the start of care.”
Hospital Issued Notice of Non-Coverage (HINN):
?Written notices given by a hospital to
tell a patient that Medicare may not cover his or her admission, inpatient status or continued stay while at
the hospital. This allows patients to be fully informed about decisions they must make that are affected by
their Medicare coverage as well as payment for an inpatient stay at the hospital. HINN letters are
delivered to beneficiaries prior to admission, at admission, or at any point during an inpatient stay when
the hospital determines services the patient is receiving, or about to receive, are not covered because the
services are not medically necessary, not delivered in the most appropriate setting or are custodial in
nature.
Last inpatient day:
The day before the patient is discharged is the last inpatient day.
An inpatient admission
An inpatient admission is generally appropriate when a patient is expected to need two or
more midnights of medically necessary hospital care, but the doctor must order such admission and the
hospital must formally admit the patient in order to be termed inpatient
Long-Term Acute Care Hospital (LTACH):?
A specialized care facility designed to treat
acutely ill patients who benefit from a prolonged LOS for a minimum of 25 days. LTACHs differ from
nursing homes and inpatient rehabilitation facilities. The significant difference is LTACHs are inpatient
facilities with full-time registered nurses and physicians who provide care 24-hours a day, seven days a
week. LTACHs are equipped to provide the same level of care as acute care hospitals with the exception
of emergency medical services, obstetrics and gynecology services. LTACHs are needed because they
help free beds in acute care hospitals, particularly in intensive care units.”
Medicaid Integrity Contractors (MIC):
A contractor responsible for ensuring that paid
claims were for (1) services provided and properly documented, (2) services billed properly, using correct
and appropriate procedure codes and (3) covered services. MICs additionally insure that claims are paid
according to Federal and State laws, regulations, and policies. There are three types of MICs - review,
audit and education.
Differences of Medicare ABCD
Medicare Part A covers inpatient hospital services
Medicare Part B covers outpatient
medical services
Medicare Part C consists of Medicare Part A and Part B benefits that offer a choice between an open-network single-payer plan (traditional Medicare) and a network plan (Medicare
Advantage), where the federal government pays for private health coverage.”
Medicare Part D covers outpatient prescription drugs exclusively through private plans,
either standalone prescription drug plans or through Medicare Advantage plans.”
Medicare Spending per Beneficiary (MSPB):
A Medicare hospital spending claim that
includes all of Medicare Part A and Part B claims paid during the period from three days prior to a
hospital admission through 30 days after discharge
Nursing Home Compare:?
A Medicare.gov website that stores detailed information about
every Medicare and Medicaid-certified nursing home in the country. States may collect and post
additional information that is not collected by the federal government
Office of the Inspector General (OIG):
The Office of Inspector General (OIG) investigates
allegations of fraud, waste, abuse or misconduct within the executive branch of federal government. The office also assists residents with locating the proper agencies to address concerns, when necessary.
Furthermore, the OIG assists executive branch entities in identifying and correcting operational
deficiencies.
Power of Attorney (POA):
A written authorization to represent or act on another’s behalf
in private affairs, business or some other legal matter. The person authorizing the other to act is the
principal, grantor or donor of the power, and the one authorized to act is the agent, donor or attorney, or in
some common law jurisdictions, the attorney-in-fact. Formerly, a power referred to an instrument under
seal while a letter was an instrument under hand, but today both are under hand (i.e., signed by the donor),
and therefore there is no difference between the two.Durable Power of Attorney simply means that the
document stays in effect if you become incapacitated and unable to handle matters on your own.
(Ordinary, or “nondurable,” powers of attorney automatically end if the person who makes them loses mental capacity.)Healthcare Power of Attorney is a legal form that allows an individual to empower
another with decisions regarding his or her healthcare and medical treatment. Healthcare power of attorney becomes active when a person is unable to make decisions or consciously communicate
intentions regarding treatments.”
Pre-Admission Screening and Resident Review (PASRR):
Under State and Federal Law,
PASSR applies to individuals who are: (1) being considered for admission to a nursing facility or (2) are already residents of a nursing facility and have a significant change in their physical or mental condition
Project Boost Risk Assessment:
risk assessment tool kit developed by the Society for
Hospital Medicine.”
Qualifying Stay:
For a Medicare patient to access benefits for a skilled rehabilitation or
nursing stay after discharge from an acute hospital, the patient must have a three-day, medically
necessary, qualifying hospital inpatient stay.”
Situational Judgment Tests (SJTs) or Inventories (SJIs):
A testing methodology where the
test taker is presented with realistic, hypothetical scenarios and ask to identify the most appropriate
response or to rank the responses in the order they feel is most effective.
Skilled Nursing Facility (SNF):?
A facility that provides healthcare when an individual
requires skilled nursing or rehabilitation staff to manage, observe and evaluate a patient?s care. Medicare
Part A provides payment for post-hospital care in SNFs for up to 100 days during each illness. An illness
begins on the first day a patient receives Medicare-covered inpatient hospital care and ends when the
patient has spent 60 consecutive days outside the institution, or remains in the institution but does not
receive Medicare-coverable care for 60 consecutive days. Once met, the patient is entitled to full coverage
of the first 20 days of SNF care. From the 21st through the 100th day, Medicare pays for all covered
services except for a daily co-insurance amount, which is adjusted annually.”
Uniform Health Care Decisions Act of 1993 (UHCDA):
This Act consolidates various
state laws dealing with all decisions about adult healthcare and healthcare powers of attorney. It aims at
assisting individuals and the medical profession in better assuring a person’s right to choose or reject a
particular course of treatment. This act is designed to replace existing living will, power of attorney for
healthcare and family health care consent statutes which are dealt with separately in most states.”
What are the first steps in conducting an assessment?
1)Establish rapport.
Establishing rapport is key to a thorough assessment as the patient is more likely to share detailed information if there is a level of trust.
2)Verify demographic information in the record.
This is an important step in an assessment, since errors could result at the time of discharge (for example equipment being sent to the wrong address).
Does CM verify insurance coverage?
Insurance verification is not the job of the case manager. Patient Access/Registration will be pre-authorizing the surgery, and the case manager will want to know at a later stage the specific benefits for discharge planning.
(this is in reference to what are the first steps in conducting an assessment?)
Description in question states that patient is independent in ADLs. Would CM want to evaluate ADLs?
Evaluate ADLs
The description of Ms. Xavier already states that she lives alone and is independent in all of her ADLs. There is no need to re-evaluate.
Question: conducting an assessment- would the CM Contact the Healthcare Power of Attorney to request verification documents?
If the patient is awake, alert, and capable of making her own health care decisions, there is no need to invoke the provisions in the Healthcare Power of Attorney document. It may be a facility’s policy to have these documents on file prior to a surgery, but this should not be pursued without first talking with the patient.
Pre-surgery CM assessment: After rapport is established and demographics have been verified, the first question the case manager asks is
“what is your understanding of the care you will need after this surgery?”
Pre surgery CM assessment, CM asked “what is your understanding of the care you will need after this surgery?” Patient says she expects to get back to regular activities quickly. What are next steps?
+2
Point out that after surgery, everyone requires some assistance, and address this need with the question, “will your children be willing, able and available to provide the physical assistance you will need and to stay with you until you progress to the point where you feel independent again?”
Good answer, but the case manager also needs to know what the care needs will be to better assess the family’s ability to provide the care.
+3
Ask the patient to describe what she understands about the care that will be required when she is discharged and returns home.
This is the best answer as it allows the patient to tell the case manager what she thinks will be needed, and it allows the case manager the opportunity to correct/adjust those ideas (based on experience and the patient’s prior level of functioning) to a more realistic assessment, if necessary.
(do NOT discuss SNF at this time)
presurgery CM assessment: After establishing that the patient has a clear understanding of what her care needs will be and that her children are willing, able and available to help her, what are the next questions(s) the case manager will ask?
+3
What are the number of steps to get into the house/apartment?
This is more relevant than the question above and can also be phrased as, “will the patient have difficulty getting into her home?”
+2
Are the bedroom and bathroom on the first floor?
This is also important. The case manager will need to determine, once the patient is in the home, whether they will be able to get to the bathroom and bedroom or require some form of assistance.
+1
Does the patient know if the doors in her home are wide enough for a walker to fit through?
This will be important to know if getting around the home presents a safety issue.
NO -2- wrong answer
What is the patient’s insurance coverage?
This will be asked later in the assessment, but not yet.
NO -3- wrong answer
Are there neighbors, or friends, willing to provide assistance?
While friends could be a part of a discharge plan, at this point this is irrelevant since she has a caregiver.
pre-surgery assessment :After assessing the physical environment, what is/are the case manager’s next concern(s)?
+3
Determining the patient’s insurance coverage for post-acute services.
At this point in the assessment, it is important to now assess the financial resources for needed services and open a conversation with the patient and/or family about limitations, if applicable. For example, the case manager knows that the patient has a Managed Medicare product and should share with the patient that access to home health or SNF will be based on therapy notes and need for rehab rather than the patient simply wanting to recover in a nursing home. Do remember that since she has Managed Medicare, her payer may allow SNF placement, if needed, without a 3-day stay.
+2
Clarifying the patient’s prescription benefit, including co-pay requirements.
The case manager knows that patients are discharged on anti-coagulants after joint surgery, and based on experience, the case manager knows these drugs can be expensive.
+1
Exploring with the patient her available resources and ability to make co-payments.
The patient may or may not have financial concerns, but education about how much these drugs could cost is important for all patients in order to prevent a surprise at discharge.
-2- NO- wrong answer
Determining who the patient’s primary care physician is.
This information should be contained in the record and should have been verified with the patient earlier in the assessment.
-1 NO- wrong answer
Determining what home health agency the patient wants to use, if needed.
Although a good question, this is not the next step. The case manager needs to check benefits, and since this is Managed Medicare, also check preferred providers before having this conversation.
-3 NO- wrong answer
Showing the patient how to use Medicare.gov to assist in choosing a SNF.
SNF placement is not in the care plan at this point. If it becomes necessary, the case manager must check first for in-network providers with Managed Medicare payers. In most Medicare Advantage plans, the patient needs to use plan doctors, hospitals and other providers or pay more or all of the costs (Medicare.gov website).
