Hospitals traditionally have focused the efforts of their utilization management committees (UMCs) on individual attending physicians and inpatient stays, with an eye on complying with the Centers for Medicare & Medicaid (CMS) conditions of participation for hospital utilization management. But is that enough, in light of new CMS focus areas such readmissions, post=acute care transfer (PACT) rules, qualifying three-day inpatient stays for skilled nursing facility placement and renewed scrutiny on patient transfers and how hospitals bill? All of these rules affect how hospitals track patients, from readmissions to verification of appropriate placement in post-acute care, in orderto ensure compliance with level of care ordered on discharge.
On top of those aforementioned issues, we also have the current regulatory environment to deal with, plus patient-centered continuum of care efforts such as the accountable care organizations (ACOs), the medical home concept, and bundled payments. These are complex matters, all aimed at the inpatient hospital “owning” or guiding patients throughout the process of being provided care. Whether we like it or not, hospitals are being teed up to manage, or at least follow, the whole care continuum for individual patients.
So, how can hospitals maximize the rendering of outpatient and post-acute services to improve inpatient efficiency and compliance? This may be a difficult issue for many hospitals due to the inaccessibility – either due to geography or capacity – of post-acute services. In addition, factors such as patient choice and non-funded patients can make it overwhelming for care managers and hospitals to navigate the continuum of care and make full use of post-acute care options. However, if hospitals can overcome barriers to access, ensuring the effective and compliant use of post-acute care services will pay off through reduced lengths of stay, reduced readmissions and improved financial performance.
We recommend that facilities start by identifying all post-acute services in their primary and secondary areas and mapping the services by location, services offered and payers accepted. Overlay historical hospital usage of post-acute care services to determine use of existing facilities or services. Make sure you are utilizing all available resources. Next, query the care coordination department on discharge barriers they encounter and note the frequency with which each barrier is confronted (this should already be tracked as excess days for UMC).
As an example of such a barrier, a provider may not accept patients on IV therapy. Another provider may have no weekend admissions, or it will accept only insured patients. Take notes on how your team tried to resolved such problems in the past and categorize each approach by what worked and what didn’t – or by examining what only worked some of the time, or only with specific providers. Once this analysis is complete, form a task force led by care coordination to develop solutions and work with outpatient and post-acute providers.
Also, be proactive and approach the post-acute providers to meet and discuss how the continuum could be improved. Have a clear plan for how you would like to collaborate with such providers on an ongoing basis. For example, facilities may develop care plans across the continuum, or they may allow for a post-acute care liaison to participate in discharge planning for inpatients.
Also, assist facilities in meeting your patients’ needs. For instance, if IV management is an issue for a post-acute provider, other facilities may assist in education, or other post-acute care facilities may subcontract an acute-care hospital to provide such services. If a facility does not admit on the weekend, negotiate a “fast-track” procedure driven by a plan of care to reduce the internal burden on an accepting facility. For non-funded patients, consider a strategy to allow for hospital-sponsored discounted payments to a post-acute provider. Paying for the post-acute service is often more cost-effective than maintaining a patient in the acute-care setting, and doing so will free up acute beds. These are opportunities to create solutions that work for the inpatient and post-acute providers, as well as the patients.
Another wise step would be to improve the list of providers given to your patients by listing each facility’s offered services and any other provider-specific information, such as payers accepted. A well-organized list of facilities with a summary of capabilities can help patients and families understand how choice is not just about convenient location, but services that match their needs.
Also, determine how to evaluate your post-acute providers, perhaps by creating a database to track readmissions by provider and developing scorecards for your post-acute partners. Doing this may highlight areas of opportunity to improve quality of care across the continuum. Collaborate on education and share resources used to address critical issues such as the PACT and compliance. Ask post-acute providers for quarterly reporting on mutually agreed-upon quality metrics and even invite a facility to the UMC to report on its services and meet the physicians. Make cooperation a positive experience.
In closing, inpatient hospitals and their UMCs should have a far broader scope than merely focusing on inpatient services. What happens when a patient leaves the inpatient facility can impact the inpatient provider directly in terms of readmissions and compliance. By collaborating with providers outside your walls, you will improve care throughout each patient’s episode of care.
About the Author
Elizabeth Lamkin, MHA, is CEO of PACE Healthcare Consulting, LLC in Hilton Head S.C. After 20 years as a highly innovative hospital CEO, she now brings effective solutions to all types of hospitals and healthcare providers. Because Elizabeth has served as a manager at every level in a hospital including multi-unit CEO, she has a unique perspective on the micro and macro operations of a hospital.
Elizabeth specializes in system development, quality and compliance with a focus on billing and HIPAA. She is a nationally known speaker and author on billing compliance including CMS Recovery Auditors.
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 “OIG HHS Work Plan, FY 2013”. https://oig.hhs.gov/reports-and-publications/workplan/index.asp#current. Page 3. Accessed Oct. 12, 2012.