a publication for hospital and health system

8/14/2019 A Publication for Hospital and Health System

1/16

A P u b l i c a t i o n f o r H o s p i t a l a n d H e a l t h S y s t e m P r o f e s s i o n a l s

T h e O f f i c i a l P u b l i c a t i o n o f t h e A m e r i c a n C a s e M a n a g e m e n t A s s o c i a t i o n

F A L L 2 0 0 9 V O L U M E 7 , I S S U E 3

4Making Informed Choices: Care for Patients Lacking Decisional Capacity

4Care for the Undocumented and Uninsured Population

4The Power of Partnerships: Employing a Multidisciplinary Approach

to Reduce Neurosurgery Length of Stay

4A Growing Concern: Care of Patients with Antibiotic Resistant Infections


2/16

C A S E M A N A G E M E N T

Case Management in Hospital and Health Care Systems is a

collaborative practice model including patients, nurses, social workers, physicians

other practitioners, caregivers and the 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.

A p p r o v e d b y A C M A M e M b e r s h i p , N o v e M b e r 2 0 0 2

F A L L 2 0 0 9 V O L U M E 7 , I S S U E 3

Publisher

L. Greg Cunningham, MHACEO

ACMA / Little Rock, [email protected]

editorial staff

Randall ArcherEditor

ACMA/Little Rock, [email protected]

Tyler NeeseEditorial Staff

ACMA/Little Rock, [email protected]

editorial board

Jane Hounsell, MSW, LCSWLead Medical Social WorkerCase ManagementColumbia-St Marys Hospitals/Milwaukee, WI

Val Kraus, MBADirector

Admissions / Case Management / ChaplainBoulder Community Hospital/Boulder, CO

Sandra Mullings, MSW, LCSW, C-ASWCM

DirectorCare CoordinationEmory Crawford Long Hospital/Atlanta, GA

Charlotte Spacek, RN, MSN, MBA-HCM, CPUMDirectorCase ManagementMartin Memorial Health System/Stuart, FL

Tricia Thomas, PhD, RN, MSNAssistant Professor and CoordinatorClinical Nurse Leader Program

University of Detroit Mercy/Detroit, MI

Collaborative Case Managementis publishedquarterly by the American Case Management

Association (ACMA), 11701 West 36th Street,

Little Rock, AR 72211.Telephone: 501-907-ACMA (2262).

Subscription is a benefit of membership in ACMA.Full and Associate memberships are available at$135.00 per year. Student membership is open toindividuals enrolled in a full time academic programat $60.00 per year. More detail about membershipcategories is available at the ACMA web site,

www.acmaweb.org or by calling 501-907-2262.An annual subscription is available for non-members at $100 per year. Single issues can bepurchased by non-members for $25.00 per issuesubject to availability.

Photocopying: No part of this publication may bereproduced in any form or incorporated into anyinformation retrieval system without the writtenpermission of the copyright owner. For reprint

permission, please contact ACMA,11701 West 36th Street, Little Rock, AR 72211.

The statements and opinions contained in thearticles ofCollaborative Case Managementaresolely those of the individual authors andcontributors and not of the American CaseManagement Association. The Publisher and Editordisclaim responsibility for any injury to persons

or property resulting from any ideas or productsreferred to in the articles or advertisements.

Copyright 2009American Case Management AssociationAll rights reserved

2

3Making Informed Choices: Care for Patients

Lacking Decisional CapacityBy Wes Collins, BA, MA

7 Care for the Undocumentedand Uninsured PopulationBy Mea Austin

10 The Power of Partnerships:Employing a Multidisciplinary Approachto Reduce Neurosurgery Length of StayBy L. Ann Teske, MS, RN

13 A Growing Concern: Care of Patientswith Antibiotic Resistant InfectionsBy G. Michael Lynch, MD, FAAFP and

Linda Sallee, RN, MS, CMAC, CPUR, IQCI

I n T h I s I s s u


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This article will examine the concept of autonomy in the

healthcare setting, explore the development of a clinical assessment

tool, and present a collaborative approach to managing this patient

population efficiently.

AUtOOMy

The concept of autonomy carries with it significant ethical and

legal implications, and was proposed as early as 1914 in the case of

Schloendorff v. Society of New York Hospital1. In this case issued by

the New York Court of Appeals the plaintiff, Mary Schloendorff, was

admitted to New York Hospital and consented to an abdominal

examination under anesthesia to determine if a diagnosed fibroid

tumor was malignant. However, Schloendorff did not consent for

the removal of the tumor. The physician examined the tumor,

determined it was malignant, and then removed the tumor against

Schloendorffs wishes. Following the courts ruling, Justice Benjamin

Cardoza delivered an opinion that has become a classic statement

for a patients right to self-determination. Cordoza stated that every

human being of adult years and sound mind has a right to

determine what shall be done with his own body. 2

The Schloendorff case has proven to be significant not because

of the courts decision, (the case focused on the liability of the

hospital for wrongful acts committed by surgeons using its facilities,

and the court neither found a violation of informed consent, nor

addressed the amount of information a patient needs in order to

exercise his or her right of self-determination) but because Justice

Cardoza explored for the first time the principle of autonomy.2

Respecting a patients autonomy requires, at minimum, the

acknowledgment of an individuals right to have their own opinions,

make choices, and take actions based on personal goals and values.

Truly autonomous choices share the following three characteristics:

1) The choices are voluntary

2) The choices are not coerced

3) The choices are based on sound reasoning

With these factors in mind, the issue of decisional capacity and

respect for ones autonomy are pivotal in developing an appropriate

plan of care for a patient.

DEVELOpI A CLIICAL ASSESSMEt tOOL

The reality that not all organizations employ formal and

consistent methods when assessing D-MC may be largely

attributed to common misconceptions about D-MC (see Figure A),

as well as a lack of formal assessment tools or universal formulas

available for determining a patients D-MC. In 2004, the Palliative

Care Services Department at Spartanburg Regional Healthcare

System (SRHS) in Spartanburg, SC, identified the need for a clinical

tool to properly assess D-MC, and began to develop a solution.

A tEAM EFFOrt

The Palliative Care Services Department drove thedevelopment of a clinical assessment tool, but also recognized that

there are a variety of specialists and members of the medical staff

that interact with patients lacking D-MC, and are influential in

caring for this patient population and thus could contribute

valuable insights into assessing D-MC in different phases of care

and in different care settings. Therefore the first step in the

development process was to solicit these individuals thoughts as to

what an effective clinical assessment tool should include, and what

specific criteria should be taken into consideration.

Making Infomed Coices: Cae fo paiens Lacking Decisional CaaciBy Wes Collins, BA, MA

te incile of auonom, o self-deeminaion, is a fundamenal ene of medical eamen in e Unied Saes, and a ke consideaionwen caing fo aiens wo lack decisional caaci. paiens wo ae unable o make auonomous coices and lack decision-making

caaci (D-MC) ae consequenl no emoweed o make ei own ealcae decisions. Unfounael, oweve, no all ealcae

ovides assess D-MC fomall and consisenl.

continued on page 4

C O L L A B O R A T I V C A s M A n A G M n T

1. D-MC and competency are the same

2. Lack of D-MC can be presumed when patients

go against medical advice3. There is no need to assess D-MC unless patients

go against medical advice

4. D-MC is an All or Nothing phenomenon

5. Cognitive impairment equals lack of D-MC

6. Lack of D-MC is a permanent condition

7. Patients who have not been given relevant andconsistent information about their treatmentlack D-MC

8. All patients with certain psychiatric disorderslack D-MC

9. Patients who have been involuntarilycommitted lack D-MC

10. Only mental health experts can assess D-MC

10 Common misConCePtions ofdeCision-making CaPaCity4

FIUrE A


4/16

The Palliative Care Services Department also recognized that

those outside the medical care team could have critical perspectives

on a tool to assess D-MC. Geriatric patients are a key demographic

for decisional capacity issues, and thus the geriatric psychiatry

department was instrumental in developing the criteria used in the

assessment tool. Due to the legal ramifications surrounding D-MC,

the organizations legal counsel was asked to review every aspect of

the tools development as well to ensure that it would protect the

patients right to autonomy and decisional capacity. The behavioral

health department also provided valuable feedback, and the

organizations director of case management helped mold the tool

by providing insight as to what criteria would be critical to evaluate

a patients degree of preparedness for discharge or transition. The

ethics committee at SRHS also provided a thorough review of the

tool, as assessing D-MC carries significant ethical implications.

thE AAtOMy OF thE tOOL

South Carolina law states that in order to designate a patient as

lacking decisional capacity, two physicians involved in the patients

plan of care must indicate that the patient is incapable of making

medical decisions. In accordance with this law, the Palliative Care

Services Department at SRHS developed a clinical assessment tool

consisting of a single page, pre-printed progress note with two

identical columns one per physician that is part of the patients

medical record (see Figure B).

The form is designed so that the attending physician completes

one side of the progress note, and the second side of the form is

completed by a second physician that is involved in the patients

plan of care. Each side of the form has two options accompanied by

check boxes This patient DOES possess the decisional capacityto make healthcare decisions for self, or This patient DOES NOT

meet ALL of the criteria for decisional capacity, therefore is not able

to make healthcare decisions for self. Furthermore, it is my opinion

that due to the patients medical condition(s), this lack of capacity is

not likely to change in the immediate future.

If the physicians indicate the latter, they must then select the

criteria not met for decisional capacity, and their orientation to

person, place, or time. These criteria include:

Understands the nature of his/her illness

Ability to understand that decisions need to be made

Ability to communicate a decision

Ability to understand and use information

logically to reach a decision

Ability to be realistic in decision making (i.e. to understand

the consequences of a decision)

Space is then allotted for the physicians to provide their

medical rationale for determining that the patient does not possess

decisional capacity. Once completed, the physician then signs the

form. A completed and signed form from both physicians is

considered documentation verifying that the patient is non-

decisional, and thus empowers a family member or friend to be

identified as a legal surrogate, responsible for the treatment

decisions of the patient.

A COLLAOrAtIVE ApprOACh tO CArE

At SRHS, the Palliative Care Services Department and the

organizations case managers not only collaborated in developing

an assessment tool, but continue to use this tool collaboratively on

a daily basis. Case managers are a vital part of palliative cares

protocol for assessing patients and caring for those who lack D-MC.

SRHSs case management model consists of both nurses (RNs)

and masters-prepared social workers. Case managers assess any

patient being transitioned to a skilled nursing facility (SNF) who

shows signs of decreased D-MC by utilizing the clinical assessment

tool. Medical directors at area SNFs have requested that patients be

assessed for D-MC prior to their transition to the SNF, due to the

fact that often the SNFs are short-staffed and may only have one

primary physician on staff. Since the law requires two physicians to

designate a patient as lacking D-MC, assessing a patients D-MC

prior to his or her transition on to a SNF empowers SNFs who may

be short-staffed to still continue on with the appropriate plan of

care for the patient, and make the necessary medical decisions with

the consent of the patients legal surrogate. Empowering the SNF tocomply with these shared decisions also reduces the amount of

hospital readmissions for services and treatments such as

ventilators, because alternate care plans can be provided in the SNF.

Another one of case managements key responsibilities in the

care process for patients lacking D-MC involves utilization review

(UR), and coordinating UR with the appropriate plan of care for the

patient. UR is generally a standard function of case management in

many organizations; however, one factor that may differentiate the

UR process for patients lacking D-MC from the standard UR

4


Making Infomed Coices: Cae fo paiens Lacking Decisional Caaci (continued from page 3)

continued on page 6

Every human being of adult

years and sound mind has

a right to determine what shall

be done with his own body.


5/165

w w w . a c m a w e b . o r g

SPARTANBURGRegional Healthcare System

0SRMC 0SHRC 0BJW

PROGRESS NOTE ADDRESSING DECISIONAL CAPACITY

Based upon my observation and involvement with this patient, it is my medical opinion that

Account Number:(Name of Patient)

Check ONE of the following statements

This patient DOES possess the decisional capacity to makehealthcare decisions for self.

This patient DOES possess the decisional capacity to makehealthcare decisions for self.

This patient DOES NOT meet ALL of the criteria for decisionalcapacity, therefore is not able to make healthcare decisionsfor self. Furthermore, it is my opinion that due to the patientsmedical condition(s), this lack of capacity is not likely to changein the immediate future.

This patient DOES NOT meet ALL of the criteria for decisionalcapacity, therefore is not able to make healthcare decisionsfor self. Furthermore, it is my opinion that due to the patientsmedical condition(s), this lack of capacity is not likely to changein the immediate future.

Criteria not met:

Oriented to person place time




Ability to understand and use information logically toreach a decision

Ability to be realistic in decision making (i.e. tounderstand the consequences of a decision)

Criteria not met:

Oriented to person place time




Ability to understand and use information logically toreach a decision

Ability to be realistic in decision making (i.e. tounderstand the consequences of a decision)

Progress Note

Progress Note

NOTE: A Psychiatric consult is NOT required. This form requires the signature of TWO PHYSICIANS! A Progress or Consult Noteshould be written regarding both the patients medical condition and mental capacity.The completed form will be forwarded at discharge to the extended care facility.

(Attending Physician) (Date)

(Second Physician involved in Care) (Date)

Patient Label

1691 (11-04)

FIUrE


6/166


Making Infomed Coices: Cae fo paiens Lacking Decisional Caaci (continued from page 4)

process is the frequency and amount of communication involved.

Due to the fact that the patient is not able to make medical

decisions and provide input during the process, the organizations

case managers, Palliative Care Services Department, the patient,

and the patients family, must work together to communicate in

order to ensure that the plan of care is in line with the patients

wishes or values.

SRHSs case managers are also responsible for securing any

necessary outside resources, such as ancillary service providers and

SNFs, as mentioned above. Patients following a more medically

complex plan of care often require case management and palliative

care to work closely together when making arrangements with

outside providers. The collaboration between case managers and

palliative care helps determine the best plan of care for the patient,

and ensures proper utilization of resources.

ChALLEES ECOUtErED

As with any process or initiative, there are a number of

challenges encountered when developing a plan of care for patients

who lack decisional capacity, perhaps the greatest of which is

communication. Communication between all parties involved in

the patients care is central to developing and properly executing an

effective care plan.

The American Academy of Neurology (AAN) states that

life-sustaining treatment decisions in patients who have lost theirdecision-making capacity must first and foremost respect the

autonomy of the patient and/or the immediate family.3This

concept proves to be particularly challenging in terms of

communication when working with patients who lack both the

ability to communicate their wishes, and formal documents such

as legal advanced directives which clearly dictate their wishes and

values. In such cases, medical decisions must be made based on the

interpretation of the immediate family. Such cases are especially

challenging when large families are involved, as there are varying

interpretations and ideas as to what course of action is best for their

loved one.

Patients families are also often unaware of the legal

implications surrounding the care of their loved one. This proves to

be a major challenge in determining consent for treatment plans, as

a patients son or daughter might believe that as the eldest child,

they are entitled to be the legal surrogate. This is not always the

case, and laws and statutes dictating the priorities of who is

appointed legal spokesperson or surrogate vary by state. In fact, the

absence of an advanced directive indicating a proxy or a specific

legal surrogate often establishes a shared power, which requires a

consensus among the family.

COCLUSIO

When developing a plan of care for patients lacking D-MC,

consideration must be given to all those that will be involved in the

patients treatment. Every member of the care team from the case

managers responsible for the patients utilization, to his or her

attending physician must provide input and feedback as the

patients plan is crafted in order for treatment to be truly effective

and as seamless as possible.

Careful consideration must also be given to the legal, ethical,

and moral implications involved with patients without D-MC. Legal

counsel, risk management, ethics programs, psychiatric programs,

and physician leaders are all valuable and necessary resources to

consult when developing a plan of care for patients lacking D-MC.

SRHSs collaborative care model for patients lacking D-MC notonly provides quality patient-centered care for the patient, but also

supports the patients autonomy and right to self-determination.

Furthermore, by developing a tool that adequately assesses D-MC,

the staff at SRHS has ensured that due process is followed in

designating patients as not possessing D-MC, while acting in the

patients best interest clinically, morally, and ethically.

Wes Collins BA, MA, has been the Advance Care Planning and

Clinical Ethics Coordinator at Spartanburg Regional Healthcare

System since 2003. He earned his MA from Oral Roberts University

in Tulsa, Oklahoma. Wes has 30 years of experience in the areas

of advance care planning, pastoral care and clinical chaplaincy,

counseling, and clinical ethics.

rEFErECES

1 Schloendorffv.SocietyofNewYorkHospital, 211 N.Y. 125,105 N.E. 92, (1914).

2 AHistoryandTheoryofInformedConsent, Ruth R. Faden & Tom L.

Beauchamp, P.123-124.

3 American Academy of Neurology, Position Statement, 1988.

4 Ten Myths About Decision Making Capacity,JournalofAmericanMedicalDirectorsAssociation , July/August 2004.

The absence of an advanceddirective indicating a proxy

or a specific legal surrogate

often establishes a shared

power, which requires a

consensus among the family.


7/16

continued on page 8

7


There are limited resources available to cover the medical

expenses of non-citizens. Even some legal permanent residents

are not eligible for standard coverage. Providing care for this

population challenges the resource network and creativity of case

managers. As a foundation for effectively serving this population,

case managers need to have an understanding of their situation

and the external forces that can complicate care delivery.

UDErStADI UDOCUMEtED ALIES

There are already eight to twelve million undocumented

immigrants in the United States, and for most there is no feasible

path to gaining citizenship. Why are there so many undocumented

aliens in the U.S.? Why do they refuse to follow the rules and enter

the country legally? For many, particularly those from Mexico and

Central America, the answer is simple; they do not want to be

separated from family. A Mexican citizen may have to wait 22 yearsto legally bring his unmarried son or daughter to the United States.

A Legal Permanent Resident may have to wait seven to ten years to

reunite with a spouse and children; this is a sacrifice few would be

willing to make.

Families must remain separated while they complete a lengthy,

complex and expensive process. The application process requires

numerous steps and forms and may seem very overwhelming to a

potential immigrant. The average cost for a family-based residency

petition is $1,745. In addition to these fees, the applicant is required

to have a sponsor with an income of at least 125% of the poverty

guideline. Sponsors must be willing to support the immigrant for

up to ten years, and open themselves to examination of personal

finances by the federal government. The realities of the path tocitizenship or residency are harsh.

Understanding is the foundation. The reality is that this is a

challenge health systems and providers will likely be facing for quite

some time. Case managers are at the intersection of the United

States historical and present immigration policies, and the current

realities of providing quality healthcare to these individuals while

ensuring the financial health of the provider organizations.

Once one comprehends how difficult it is to obtain citizenship,

the reason for the high numbers of undocumented aliens is

obvious. Undocumented immigrants are not leaving, and they will

continue to cross U.S. borders. To lessen the burden this creates on

communities throughout the country, healthcare providers must

effectively utilize all available resources to cover the cost of their

medical care.

SOrA

Although coverage options are limited, there are resources

available to help cover medical expenses for undocumented aliens.

The most common benefit is the Sixth Omnibus Budget

Reconciliation Act, commonly known as SOBRA. The act was

designed to protect medical facilities that are subject to the Federal

Emergency Medical Treatment and Active Labor Act (EMTALA).

EMTALA was passed in 1986 amid growing concern over theavailability of emergency health care services to the poor and

uninsured. The statute was designed principally to address the

problem of patient dumping, whereby hospital emergency

rooms deny uninsured patients the same treatment provided

paying patients. SOBRA was created to decrease the financial

burden of treating the uninsured that came with the

implementation of the EMTALA.

SOBRA provides medical benefits to aliens who are not

lawfully admitted to the United States. This program does not

Cae fo e Undocumened and Uninsued poulaionBy Mea Austin

Give me your tired, your poor, your huddled masses.

Do you eve wonde if e famous inscipion on e Saue of Libey as been placed above you ospial emegency oom enance?

Suc an inviaion o e wold and all people oping o impove ei lives is, isoically, unpecedened, and a defining elemen in e

pesonaliy of e Unied Saes.

howeve, caied fowad o oday is defining elemen of e Unied Saes as also come o ceae significan callenges

fo is ealcae sysem specifically, ow o cae fo e undocumened and uninsued populaion wen ey ae no eligible fo mos

public benefis, and ow o ensue a ospials and communiies ae no foced o absob e cos of cae fo ese individuals.

Case managers are at theintersection of the United States

historical and present immigrationpolicies, and the current realities

of providing quality healthcare tothese individuals while ensuring

the financial health of theprovider organizations.


8/168


cover aliens admitted with a visa that means students, employees,

anyone who is admitted temporarily and legally. It does not cover

Legal Permanent Residents of less than five years (to the day). The

alien must have a qualified emergency medical condition and

meet the income, resource, and categorical requirements of a State

Medicaid Program. SOBRA is not a Medicaid program; it is an

additional requirement that allows undocumented aliens to obtain

minimal Medicaid coverage. The coverage is specific to emergency

treatment to the point of stabilization, as it is framed around the

EMTALA requirements for treating the uninsured.

There is no single definition of what constitutes a qualified

emergency. The definition of emergency services used to

determine SOBRA coverage varies from state to state. Most

definitions include the requirement of severe pain that would put

the patients health in serious jeopardy without immediate

attention. It is a good rule of thumb to determine if the patient

could have scheduled an appointment to obtain treatment

without any dire consequences. If the patient could have been

treated during business hours by a physician, there is no

emergency condition.

To help determine the nature of services that qualify as

emergent, it is helpful to utilize a hospitals prior experience in

processing SOBRA claims. In addition to analyzing prior claims,

review the medical records for each potential SOBRA claim.

Determine how the patient arrived at the hospital. Did the patient

arrive by ambulance or did they arrive on their own? Was the

patient bleeding, paralyzed, unconscious? Was the patient admittedor treated and released from the ER? An admission to the ICU offers

evidence of a qualified emergency condition.

trADItIOAL FUDI SOUrCES

SOBRA is not the only benefit available to undocumented alien

patients. There are a number of traditional benefits that may be

available to undocumented patients. Over eighty percent of the

undocumented individuals in the United States use a fraudulent

social security number to work. These individuals frequently work

in traditional jobs where health care benefits are available. Inquire

about health insurance and check in to activating COBRA benefits

for patients who were insured within the last sixty days.

Undocumented aliens can often obtain significant coverage for

medical expenses incurred as the result of a crime. Most states have

some sort of fund to assist the victims of crime with medical

expenses related to the crime. Crime victim funds do not always

prohibit payment for undocumented individuals. If the states

policy does not contain language prohibiting payment for

undocumented individuals, it is generally safe to assume that

there is a dont ask, dont tell policy.

Although it is not a significant payment source, auto insurance

may be available when services are related to an auto accident. The

same is true for accidents connected to property and covered by

home owners insurance. If the patient incurred injuries that may

be covered by an auto or home policy, he or she has every right to

make an inquiry and submit a claim.

When the majority of the undocumented patient population

is coming from one particular area, it is wise to attempt to create a

relationship with the consulate and healthcare providers from

that area. Many consulate offices have funds that are specifically

ear-marked to pay travel expenses for citizens who become ill

while abroad.

Many states also offer additional Medicaid programs that cover

testing and treatment of tuberculosis (TB). Coverage normally starts

at the time of testing and extends to discharge or verification that

TB was ruled out. The only qualifying factor is the potential

diagnosis of TB. If the patient is ultimately found to be free of thediseases, the program should still cover the diagnosis and isolation

period. When available, this can be a valuable resource for covering

undocumented patients being treated or screened for TB.

As a last resort, Medicare Modernization Act (MMA) Section

1011 funds can be utilized. The Section 1011 fund was created

under the Medicare Modernization Act. The fund consisted of

$250 million per year for 2005-2008, distributed by state, based on

the percentage of aliens in each state. One-third of the funds were

divided between the states with the highest number of

undocumented aliens; Arizona, California, Florida, New Mexico,

New York, and Texas. Two-thirds of the funds were divided between

the other states. The program was discontinued following the first

quarter of 2009; however, states with remaining funds have beengranted permission to utilize those funds.

The two primary qualifying factors for MMA are receipt of

emergency services (identical to SOBRA) and the inability to

qualify for any other benefit that would cover all or part of the

services. Payment is made directly to the hospital on a per-diem

rate for each day, up to the point of stabilization, not to exceed the

full DRG payment.

To obtain MMA funding, an organization must enroll in

the program in much the same way it signs up with other payers.

continued on page9

Cae fo e Undocumened and Uninsued poulaion (continued from page 7)

mediCare modernization aCt seCtion 1011

To learn more about MMASection 1011, and view a list of states

with remaining funds, click here.
http://www.trailblazerhealth.com/Agreement.aspx?DomainID=3&returnPath=%2fSection_1011%2fNews.aspx%3fDomainID%3d3%26ID%3d58http://www.trailblazerhealth.com/Agreement.aspx?DomainID=3&returnPath=%2fSection_1011%2fNews.aspx%3fDomainID%3d3%26ID%3d58


9/169


Cae fo e Undocumened and Uninsued poulaion (continued from page 8)

Claims are billed electronically. The facility should retain proof

of the aliens undocumented status, which can be as specific as

proof of foreign citizenship or as minimal as admission of the

undocumented status during the course of treatment. MMA

documents can and should be completed for every undocumented

claim as a back-up if another payment source fails. Eligibility

vendors should routinely create and submit the proper

documentation as part of routine benefit screenings for

organizations that contract with them.

COCLUSIO

The benefits that cover medical expenses for undocumented

patients are limited. It is important to identify and attempt to access

every potential source of revenue for every patient. A patientadmitted to the U.S. legally on a visa may be eligible for SOBRA

coverage once the visa expires. A patient injured in a car accident

may be eligible for auto insurance benefits and crime victim

benefits depending on the circumstances of the accident. The

key to gaining optimum revenue within a facility and medical

coverage for undocumented patients is benefit expertise,

diligence and creativity.

The Statue of Libertys official name represents her most

important symbol, Liberty Enlightening the World. The once

famous island is no longer the entry point for immigrants, but

its message remains relevant. It is up to case managers to ensure

that their facilities are enlightened as to the obstacles

immigrants face on the path to citizenship, and that every available

source of coverage that might pay for the care of this patient

population is utilized.

Mea Austinis Director of the Medical Assistance Program for Haaseand Long in Lawrence, KS. She developed the Medical Assistance

Program in early 1992 to assist patients and healthcare providers.

She is a graduate of Washburn University in Topeka, KS.

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10/1610


In 2007, the Clinical Case Management Department at Ben

Taub General Hospital (BTGH), part of Harris County Hospital

District (HCHD) in Houston, TX, noticed patients on the

neurosurgery service stayed in the hospital an average of 19 days.

According to national benchmarks, the average length of stay

(LOS) for hospitalized patients on a neurosurgery service was

approximately 12 days.1 This seven-day difference represented

significant cost and fiscal risk for the hospital. The realization that

BTGH was recording LOS well above the national average drove

the organizations clinical case management department to

develop effective solutions to decrease LOS.

thE EUrOSUrICAL ItESIVE CArE UIt

BTGH is a 650-licensed bed Level I Trauma Center. BTGH is

considered to be one of the busiest trauma centers in the U.S.,

with more than 108,000 patients seen each year. The Neurosurgery

Intensive Care Unit (Neuro ICU) is a 16-bed unit caring for

patients with traumatic brain injuries, gunshot wounds, strokes,

and other neurologically devastating conditions. In 2008, 547

patients were admitted to the Neuro ICU.

IDEtIFIED prOLEM

After finding that the Neuro ICU experienced an LOS

significantly higher than the national benchmark, the clinical

case management, neurosurgery, and nursing leadership met to

develop strategies to reduce the LOS on the service. During the

discussion, the leadership team identified the following

opportunities for improvement:

Hospital leadership was not visible during neurosurgery

team rounds, creating the perception that hospital

administration was not concerned about reducing the high LOS

Physical therapy did not receive referrals to assess patient

needs early in the hospital stay

Consistent, interdisciplinary collaboration was not evident

on the unit

ItErVEtIOS

To address these concerns, the care team made the decision to

increase hospital administration visibility, increase the number of

patients assessed by physical therapy within 24 hours of admission

to the Neuro ICU, and increase interdisciplinary collaboration.

The goal of increasing interdisciplinary collaboration was a

key intervention identified by the care team. At BTGH, the

rounding team was initially composed of nurses, nurse case

managers, the attending physician, the medical director of the

Neuro ICU, the director of clinical case management, and any other

physicians involved in the patients plan of care. In order to help

increase interdisciplinary collaboration, BTGHs nursing leadership

made the decision to invite a multidisciplinary team of specialists

to join the existing rounding team. This multidisciplinary team

included the organizations physical therapist, nutritionist, and

trauma outcome manager. Soon the organizations wound-ostomy

case manager, diabetes case manager, and occupational therapist

would also elect to join the rounding team. The fact that BTGHs

average LOS fell well above the national average helped orient

and motivate these various disciplines within the care team

toward the common cause of reducing LOS.

Within HCHD, a district wide-communication tool was also

employed, known as the Situation, Background, Assessment,

and Recommendation (SBAR) communication framework. Byusing the SBAR, each patients plan of care is discussed by the

entire rounding team each member of the team provides input

during this process and weighs in on the patients plan of care.

Through the use of the SBAR, any concerns regarding the 25-30

additional neurosurgery patients recovering on other nursing units

are also discussed. The rounding team then follows-up on all

concerns identified.

phySICAL thErApy/OCCUpAtIOAL thErApy SErVICES

Occupational and physical therapy services noticed that Neuro

ICU patients were generally referred to physical therapy services

one to two weeks after admission. By the time of referral, patients

have often developed contractures and a decrease in strength andmobility. The director of clinical case management and the

manager of rehabilitation services worked collaboratively to assess

processes and barriers preventing earlier assessment, with the goal

of increasing the number of patients assessed by physical therapy

within 24 hours of admission. A physical therapist also began to

attend the weekly morning rounds and work with the rounding

team to encourage referrals of appropriate patients. This strategy

created closer communications and more immediate referrals, and

also assisted the rounding team to develop skills to identify physical

Wiin ealcae insiuions ee can be a vaie of moivaos fo oganizaional imovemen. peas e mos comelling indicaoof an oganizaions need fo imovemen is naional bencmaking daa and meics comaing e oganizaion o like insiuions. Suc

daa and infomaion can seve as a song indicao of an oganizaions effeciveness, o ma iglig oouniies fo canges and

udaes o cuen ocesses and ouine ocedues.

te powe of panesis: Emloing a Mulidiscilina Aoac o reduceeuosuge Leng of SaBy L. Ann Teske, MS, RN

continued on page 11


11/1611

therapy needs in the overall plan of care for the patient. As a result,

currently all Neuro ICU patients are assessed by physical therapy

within 24 hours of admission and documentation of the treatment

plan. A further benefit has been that, by evaluating patients on the

day of admission, the rounding team is able to develop plans for

patients who are likely candidates for post-acute care.

WOUD-OStOMy CArE SErVICES

Recently, the National Pressure Ulcer Advisory Panel (NPUAP)

reported a rise in incidence and prevalence of hospital-acquired

pressure ulcers, resulting in a significant impact on the cost of

healthcare.2 Effective October 1, 2008, the Centers for Medicare

and Medicaid Services (CMS) will no longer reimburse facilities for

hospital-acquired stage III and IV pressure ulcers.3 Hence, when the

wound-ostomy case manager joined the rounding team and

explained the statistics, the physicians and nurses worked quickly

to develop appropriate interventions to prevent and treat skin

complications. Bedside discussions, linen layers on bed surfaces,

turning schedules, moisture barriers, creams, positioning devices,

and aggressive nutritional interventions were implemented

incorporating several members of the rounding team. Consults

with the wound-ostomy case manager reduced delays in initiation

of treatment and the need to use unnecessary supplies. As

evidenced in Table 1, implementation of wound-ostomy care

services on multidisciplinary rounds helped drastically reduce

pressure ulcer incident rates in the Neuro ICU.

UtrItIOAL SErVICES

Medical evidence demonstrates that initiation of enteral

nutrition within 48 hours is vital for those with traumatic brain

injury (TBI). Early TBI intervention benefits include: decreased

inflammatory response, decreased ICU infections, and improved

neurological outcomes at three months.4

Prior to the team focus on Neuro ICU LOS, nutrition

recommendations were written in the progress notes section of the

patients medical record. All too often, the notes were overlooked by

the interdisciplinary team. When the nutritionists joined the

rounding team, communication improved between physicians,

nurses, and nutritionists. The increased visibility of the nutritionist

on the rounding team also led to increased trust, understanding,and acceptance of recommendations by the nutritionist. Once the

nutritionist team began writing in the order section of the patients

medical record and obtained a physician signature, the turnaround

time of nutritionist recommendations acknowledged by physicians

went down from over 24 hours to less than 12 hours.

DIAEtES CASE MAAEMEt SErVICES

Approximately 50% of HCHD patients are diagnosed with

diabetes mellitus. Thus, the issues of diabetes prevalence and


30%

25%

20%

15%

10%

5%

0%

4 Qt. 07 1 Qt. 08 2 Qt. 08 3 Qt. 08 4 Qt. 08

te powe of panesis (continued from page 10)

25

20

15

10

5

0

Month

Days

2007 20 08 20 098

Ja n Feb Ma r A pr May Jun Ju l A ug Sep Oct Nov D ec

Month 2007 2008 2009

JAUAry 19.35 9.91 14.1

FErUAry 15.64 11.26 10.92

MArCh 17.07 9.25 9.38

AprIL 15.89 10.04 9.73MAy 17.98 9.7 12.33

JUE 13.85 13.26 9.2

JULy 13.34 12.18

AUUSt 15.25 15.06

SEptEMEr 15.92 12.39

OCtOEr 14.19 12.76

OVEMEr 13.49 10.18

DECEMEr 10.67 9.24

PerCentage of neuro iCu Patients withhosPital-aCquired Pressure ulCers (haP)

average length of stay8

tALE 1

FIUrE A

tALE 2

neuro iCu average length of stay for 2007, 2008 & 2009 8



12/1612


disease management are important initiatives for HCHD.

Additionally, effective October 1, 2008 CMS no longer reimburses

a facility if hospital-acquired poor blood glucose control results

in either increased cost of care and/or prolonged hospital stay.5

At BTGH, Neuro ICU patients frequently presented in a

hyperglycemic state.6 These patients were either heavily sedated or

recovering from serious neurological insult and often were unable

to exhibit early warning signs customarily associated with

hyperglycemia. In addition, patients on extended periods of

nothing by mouth (NPO) and bed rest made glycemic control

even more difficult.

Recognizing the importance of blood glucose control, the

diabetes case manager joined the core team in multidisciplinary

rounds. In doing so, the goals for the diabetes case manager were

to raise physician awareness of glucose levels in this patient

population, maintain glycemic control, improve patient

outcomes, and decrease LOS.7 To further address this issue, an insulin

drip order set was piloted in the Neuro ICU with encouraging results.

CArE FOr A ChALLEI DEMOrAphIC:

ADDrESSI pSyChOSOCIAL ISSUES

The majority of patients at BTGH share one or more of

the following characteristics: recent immigrants to the U.S.,

undocumented status, comparatively low socio-economic

level, language barriers, lack of understanding or trust in

healthcare, and lack of prior access to consistent, formal

healthcare. Many of these patients are also unemployed, andlive at or below the poverty level. Consequently, these patients face

a number of internal and external challenges in their attempts to

achieve optimal health and well-being. Additionally, many of the

patients do not routinely seek healthcare or receive standard

disease management, and when they present at the hospital; they

typically maintain a poor nutritional status, reach advanced stages

of illness, and often experience complications due to

co-morbidities associated with chronic illnesses.

Such specific issues and needs are identified and

addressed early in the patients hospital stay in order to decrease

their effect on the patients overall LOS. Following each weeks

round, BTGHs nurse case managers confer with two of the

organizations social workers regarding the patients plan ofcare, and any specific needs or issues that must be addressed.

Family meetings are also held early in the patients hospital stay,

and serve to foster trust, communication, and relationships

between patients, families, and hospital staff.

OVErALL FIDIS

Today, the average LOS on the neurosurgery service is

approximately nine days, well under the national benchmark

of 12 days, and a vast improvement from the previous average

of 19 days. As shown in Table 2 and Figure B (Page 11), this has been

a process of continual improvement.

As a result of the initiatives implemented at BTGH, a

partnership was developed amongst a variety of disciplines

within the organization, which allowed the care team to

collaboratively assess barriers that could be removed in order

to effectively decrease LOS and improve overall patient care

and outcomes.

L. Ann Teske, MS, RN, has been the Director of Clinical Case

Management at the Harris County Hospital District in Houston, TX

for four years. Her healthcare experience includes leadership

positions as a clinical practitioner, educator, consultant, researcher,

and administrator. She earned her BS in Community and Human

Services from The State University of New York in Albany, NY, and her

MS in Nursing Administration, with a concentration in Managed

Care for High Risk Populations, from St. John Fisher College in

Rochester, NY.

COtrIUtOrS

Zenaida Alabbasi, MBA/HCM, BSN, RN

Ruben Ceron, BSN

Sulata Daniel, BSN

Nancy DuFrane, RN, MSN, MPH, FNP-C

Dora Glaser, PT

Shanker Gopinath, MD

Leela J. Joseph, MHA, RN, BSN, CCRN, CNRN

Tina Meyers, BSN, CWOCN, ACHRN

Claudia S. Robertson, MD

Dana Wilson, RD, LD

rEFErECES

1 2007 2008 National Database for Nursing Quality Indicators (NDNQI).

2 National Pressure Ulcer Advisory Panel (NPUAP), 2007.

3 Centers for Medicare and Medicaid Services (CMS), 2007.

4 Weissman, C, 1999. Nutrition in the intensive care unit. Critical Care, 1999,3: R67-R75.

5 United States Department of Health and Human Services (HHS), 2008.

6 Weiner RS, Weiner DC, Larson RJ. Benefits and risks of tight glycemiccontrol in critically ill adults: a meta-analysts.JAMA; 2008; 300(8): 933-944.

7 Angus DC, Abraham E. Intensive Insulin Therapy in critical illness: when isevidence enough?American Journal of Respiratory and Critical Care

Medicine;2005; 172: 1358-1359.

8 Monthly Statistic Report, Harris County Hospital District Financial Planningand Budgets Department, 2007-2009.

te powe of panesis (continued from page 11)


13/16


A Medical Directors Perspective

This article will examine the implications of antibiotic resistant

infections for the patients plan of care and the patient care team,

the impact of these infections on case management, and the

possible effects on LOS.

COMMO AtIIOtIC rESIStAt IFECtIOS

Charles Darwin proposed the theory that a species strives to

preserve itself. This concept of natural selection, or survival of the

fittest, also applies to bacteria. Like other living organisms, all

bacteria react to stresses and complications in the environment.

Antibiotics represent one of those stressors to bacteria and they

respond by developing genetic variations (mutations), or by

borrowing resistance from other bacteria through transfers of

genetic material that allow survival of the species. The resulting

fittest bacteria are often resistant to multiple antibiotics.

Virtually any strain of bacteria carries the potential to develop

into a resistant bacterium. Three of the most common infections

encountered in hospitals include:

Methicillin resistant Staphylococcus aureus (MRSA)

Vancomycin resistant enterococcus (VRE)

Clostridium difficile

Of all these infections, MRSA is the most common antibiotic

resistant organism found in hospitals. Not identified until 1961,

MRSA has increased in frequency and in virulence. According to the

CDC, in 2005 MRSA accounted for more than 90,000 hospital

infections and contributed to more than 18,000 patient deaths.1 For

that year, MRSA was the cause of more deaths than AIDS, and its

cost was estimated at an excess of $21,000 per hospital infection.

EFFECt O LEth OF StAy

Resistant organisms can have a significant impact on a patients

LOS. Identifying an infecting organism, such as MRSA, as resistant

can be time consuming and may require multiple bacteriologic

identification procedures before the exact strain and antibiotic

sensitivities can be determined. For example, it may take only one

day to determine whether or not a patient has developed a

Staphylococcus species based upon the initial culture. However,

it may take an additional 24 to 48 hours to perform sensitivity

evaluations to determine which antibiotics would be effective to

treat the infection.

Technological advances including pathogen-specific agar

plates and polymerase chain reaction testing (PCR) can shorten the

time frame for identification of antibiotic resistant organisms, but

not without an increased financial cost. While it is estimated that

identification of MRSA using PCR technology could be obtained in

as little as 90 minutes compared to the usual 48 hours, that must be

weighed against the expense, which can reach nearly 10 times the

cost of standard culture techniques.

This inherent delay in identification can be costly in terms of

both time and money. If a physician initially chooses to treat an

infection with those antibiotics that are typically effective, one to

two days of therapy may pass before the organism is identified as

an antibiotic resistant bacterium. While the antibiotics can be

changed when the sensitivities are found, a delay in effective

treatment of up to two days has occurred and will increase the

patients LOS as a result.

If the physician chooses at the start to use medications that

will treat resistant organisms, the increased expense of these

antibiotics would add to hospital costs if non-resistance infections

are ultimately discovered. Additionally, indiscriminant use of the

latest and best antibiotics will ultimately stress and pressure the

affected bacteria to try to survive, and provide more opportunities

for bacteria to develop resistance.

IMpLICAtIOS FOr CASE MAAEMEt

At Inova Fair Oaks Hospital (Inova) in Fairfax, Virginia, an

integrated nurse and social work model for case management is

employed. Case managers responsibilities in the care management

of patients with antibiotic resistance infections are not unlike

standard utilization review processes and discharge planningprocedures. However, there are some notable exceptions.

At Inova, patients arriving from long term care facilities are

screened for antibiotic resistant organisms upon their admission

into the Emergency Department (ED) or Intensive Care Unit (ICU)

by each departments staff respectively. The results of these

screening examinations for colonization are provided to the clinical

case manager early in the patients hospital stay. The case manager

can then begin to make necessary arrangements based upon the

patients medical situation and plan of care. The results of the

screenings help guide not only the treatment plan, but can aid the

case manager in arranging post-discharge care.

A owing Concen: Cae of paiens wi Anibioic resisan InfecionsG. Michael Lynch, MD, FAAFP and Linda Sallee, RN, MS, CMAC, CPUR, IQCI

Anibioic esisan infecions can eesen majo baies o a aiens lan of cae, and ofen esen a miad of callenges o case

manages as e infecion can significanl affec a numbe of facos, fom leng of sa (LOS) o funding and amen fo e aiens

eamen and coninued cae.

13



14/16


14

A owing Concen: Cae of paiens wi Anibioic resisan Infecions (continued from page 13)

One aspect of case managements role at Inova that often

proves challenging is arranging for appropriate post-discharge

antibiotics to properly treat a patients infection. Antibiotics

designed to treat severe antibiotic resistant infections are often

available by IV access only. This means that in some cases, a patient

who is otherwise fit for discharge may have to remain hospitalized

until arrangements for outpatient antibiotics are completed. In

such cases, the case managers

must adjust the discharge plan

for the patient in order to make

the necessary arrangements for

IV treatment whether within

an office or hospital infusion

clinic, through a home infusion

service provider, or at a skilled

nursing facility (SNF).

If the patient is being

transitioned to a SNF, the

case manager responsible

for the patients care proactively

informs the SNF early in the

acute hospitalization so that

any necessary room

arrangements can be made.

Placing a patient with a resistant

infection in a room with a

patient who does not have the

same infection puts the other patient at risk; so many SNFs will

require advance notice when accepting patients with resistant

infections.

In cases involving a discharge to home, additional time may be

required to adequately teach the family or caretaker safe antibiotic

infusion techniques, or to arrange home infusion services.

FUDI AD pAyMEt COSIDErAtIOS

There are a number of funding implications associated with

antibiotic resistant infections. As discussed above, IV antibiotics are

commonly required to treat these infections. Whenever an IV drugis administered, there will consequently be significant cost

increases due to the preparation of the antibiotic, costs associated

with the infusion, and the actual cost of the antibiotics. Most private

insurers will pay for IV antibiotics; however, medications typically

must adhere to the insurance companys prior-approval process,

requiring further efforts by the case manager, in addition to finding

a home infusion service or a pharmacy that can provide the

medications. At Inova, this function falls under case managements

scope of responsibility as well.

The expense of the medication is often an important

consideration as well. In some instances, the antibiotic prescribed

for the patient is very costly. One commonly used antibiotic has an

average wholesale price (AWP) of $248.00 for a 500 mg vial. This

would be the daily dose for a typical adult patient. These high costs

of prescriptions can be problematic if the patient is being

transferred to a SNF, which operates on a limited per-diem budget,

and may result in non-acceptance of patients who require such

costly antibiotics. SNFs understand that they would essentially be

losing money by accepting a

patient whose drug cost is too

high for their budget.

Costly medications may

also present a challenge to

the patient who might be able

to use oral outpatient

prescription antibiotics after

hospitalization. In some

instances the patients

insurance provider may not

cover the cost of the medication

for antibiotic resistant

infections, burdening the

patient with the full cost of

purchasing the prescription.

One oral antibiotic used for

treatment of MRSA and VRE

carries an AWP of more than

$1,300 for a 10-day treatment

course of 20 tablets.

OVErCOMI OStACLES

Resistant infections can present a number of challenges to a

patients care. When employed routinely, however, there are

practices that will help minimize the impact of an antibiotic

resistant infection on a patients overall plan of care and eventual

discharge.

Early detection is the universal phrase that resounds

throughout the healthcare setting. When caring for patients with

antibiotic resistant infections, early detection and recognition arecritical, and are key to successful and efficient treatment. For case

managers, recognizing that an organism is resistant to usual

antibiotics early in the care process allows them to adjust their

discharge plan so that medication and supportive care will be

available to the patient at the time of discharge.

Recognition of a resistant infection early also allows the

patients care team to prevent the spread of infection within the

acute care facility by isolating the patient, or arranging for the

patient to be assigned to a room with another patient who has a

similar infection. It also allows for all members of the care team

to protect themselves and others by using personal protective

For case managers, recognizing

that an organism is resistant to

usual antibiotics early in the

care process allows them to

adjust their discharge plan so

that medication and supportive

care will be available to the

patient at the time of discharge.



15/16


15

equipment, such as gowns and masks.

All of these measures enable proactive planning by the case

managers, and such planning is essential when coordinating the

patients antibiotic and medication needs. Approval by insurance

companies for treatment, arranging for IV administration, and

arranging for SNF beds are also equally important. Factors such

as these represent potential delays and increase the LOS for

patients. It is essential that these factors be considered early in the

patients care plan so as to successfully overcome these barriers to

efficient care.

COCLUSIO

The unfortunate reality is that the increased use of antibiotics,combined with the laws of natural selection, will allow bacteria to

continue to develop further medication resistance. However,

medical technology and pharmacologic discoveries are also rapidly

evolving, and constantly adapting to meet patients needs and

provide improved patient care solutions. These medical advances,

combined with practices of early detection and proactive planning

can help ensure that the challenges presented by antibiotic resistant

infections are met head-on.

G. Michael Lynch, MD, FAAFP, has been the Physician Advisor for

Case Management at Inova Fair Oaks Hospital in Fairfax, VA since

2006. He has been the Chief Medical Officer at Inova Fair Oaks

Hospital since 2007, and is a Clinical Assistant Professor at Virginia

Commonwealth University - Medical College of Virginia. He is

board certified in family medicine, and a fellow in the American

Academy of Family Physicians. He earned his MD degree from

Thomas Jefferson University - Jefferson Medical College in

Philadelphia, PA. Prior to his roles at Inova Fair Oaks, Dr. Lynch

was in private practice for 28 years.

Linda Sallee, RN, MS, CMAC, CPUR, IQCI, has been the Vice

President for Case Management at Inova Health System in Falls

Church, VA since 2005. She earned both her BS and MS in Nursing

from The University of Southern Mississippi in Hattiesburg, MS.

She has more than 35 years of experience in healthcare 20 of which

have been in case management.

rEFErECES1R. Monina Klevens; Melissa A. Morrison; Joelle Nadle; Susan Petit;Ken Gershman; Susan Ray; Lee H. Harrison; Ruth Lynfield; GhinwaDumyati; John M. Townes; Allen S. Craig; Elizabeth R. Zell; GregoryE. Fosheim; Linda K. McDougal; Roberta B. Carey; Scott K. Fridkin;for the Active Bacterial Core surveillance (ABCs) MRSAInvestigators. Invasive Methicillin-Resistant Staphylococcusaureus Infections in the United States.JAMA. 2007;298(15):1763-1771.

The ACM

Certification, created by ACMA in2005, is designed specifically for Hospital Case

Management Professionals. This certification is

unique among Case Management certifications

because the examination:

Specifically addresses

case management

in the hospital setting

Utilizes clinical simulation testing methodology

to test competency beyond knowledge testing

critical thinking skills and the ability to use

knowledge in practical situations.

C e r t i f i C a t i o n

Tests core case management knowledge

that is shared by nurse and social work case

managers, as well as competency in the

individual skills of each professional background

www.acmaweb.org
http://www.acmaweb.org/http://www.acmaweb.org/


16/16

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