Refining the Continuum of Care Flashcards
steps to success in COC
- perform preadmission care planning
- perform care planning at the time of admin
- review progress of care
- conduct discharge planning
- conclude post discharge planning
what are consumers expecting of HC nowdays
more extensive and complete HC services to improve quality and longevity of lives
third party payers attempts to
maximize profits, minimize costs, and address HC fraud
public and private purchasers search for
comprehensive coverage at affordable rates
current physician struggle
paying for insurance premiums for their business
overall goal of HC sys
achieve eq between health and spending
COC
totality of HC services provided to a pt and his/her fam in all settings, from least to most exp
treating individual pt at level of care required for their course of tx
utilization management
what do you rlly need?- insurance decides what to pay for
sys review of pts receiving HC services against criteria for appropriateness of services being provided as well as admin, continued stay, and discharge planning
most you can get at the least amount of money
what is crucial for UM
evidence based decision criteria
what can insurance NOT do
anytime during your stay, insurance can tell you they will cut off coverage (not necessary), EXCEPT after discharge
adversed determination
phys appeals insurance decision to stop coverage, pt should stay admitted
Notice of noncoverage
Medicare tells their beneficiary that they won’t be covering services
why would insurance not cover services
not medically necessary, not delivered at approp time
custodial in nature
Utilization review
deciding if medical care needed according to preestablished obj screening criteria at timeframes specified in org UM plan throughout care
payment programs
pay for performance- PIP
valued based pruchasing- VBP
hospital readmin reduction program
PIP
reimbursed for meeting established metrics
VBP
came with ACA, incentivized acute care hospitals to provide better care to Medicare pts
hosp readmin reduction program
reduce payment for inpt prospective payment sys hospitals with too many readmin in certain categories
wants to improve care coordination and post discharge planning
data predicts the best outcome is when someone doesn’t get readmitted, may be best to keep them longer
domains of vbp
safety- bacteremia
clinical care - 30 day mortality rate
efficiency and cost reduct- medicare spending per beneficiary
pt com/engage- survey results
hosp outpt Q reporting prog
requires hosp to report standardized measure of care to receive full update to outpt prospective payment sys payment rage
is hosp fail to meet requirement, receive 2% reduction
UM occurs at a minimum every
3 days, must justify why continued care is necessary
case management
principal process of COC, review condition of pts to identify pt care needs, integrate data with course of tx
predetermined standard of tx for particular disease/diagnosis to facilitate pt prog, produce most desired outcome, actions to take when care is not proceeding optimally
preadmin care planning
phys contact HC org to schedule episode of care service, case manager contact payer to confirm all authorization obtained
preauthorization needs
admin crtieria met, payer will pay for services
at time of admin, case planning includes
case manager review all info to confirm criteria met, transfer occurs in facility can’t provide, critical pathway assigned
review progress of care
case manager periodically reviews pt prog t/o episode of care to see if pt continues to meet criteria for care
conduct discharge planning
starts at time of admission
consider involvement of family mem and pt, ensure their care will be continued at home
post discharge planning
CM convey info about pt course of tx to clinicians who will continue to care after discharge
indicators
performance measures that enables HC org to monitor process to determine whether it meets requirements
ex: number of admin meeting criteria/total number of admin
severity of illness- S/I
started while looking for predicted outcomes
used at preadmin or admin
how bad is it?- tells us condition of pt
what is severity of illness, can you be treated better somewhere else,
intensity of service
now that we have admitted you, where should we put you, what specified level of care is required- what is tx plan
