Lunch & Learn Sentara Care Coordination

Sally Sekowski, RN, MSN, ACM Director, Care Coordination

Sentara Healthcare

Sherry Parker, LCSW, ACMManager, Social Work Services

Sentara Healthcare

September 19, 2013

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A Vision of Change – February 2011 the Journey Begins

Our patientpatients

Sentara Hospitals

Access Care

CoordinatorsContinuum

of Care

Providers

Multi-disciplinary

Teams

Unit BasedCare

CoordinationTeam

VPMA’s/Physician Advisors

Resource Management

Center

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Crafting a Comprehensive Case Management Strategy

1) Sample staff included in rounds are physicians, nurses, physical therapists, nutritionists, etc.

1Inpatient Redesign First Step in Improving Ability to Support Broader Efforts

Multifaceted Case Management Approach at Sentara Healthcare

Phase II

Revitalized Multidisciplinary Rounds: Representatives across different clinical disciplines collaborate to conduct joint rounds and create a patient-centeredcare plan1

Care Coordination Dyad Model: Social worker and care coordinator paired to improve coordination of care; staffing ratios re-evaluated to ensure adequate support

Access Coordination:Case managers embedded at all points of patient access (e.g., ED, OB, etc.) to ensure appropriate level of care provided

Resource Management: Centralized corporate office conducts utilization review, discharge planning

Medical Necessity Reviews: VPMA advisors, with support from external agency, reviews cases, interfaces with medical staff

Phase I

Phase III

Post Acute Partnerships: Case management leaders will collaborate with post-acute care providers to improve transitions, information exchange, unnecessary transfers

Enhanced Technology: Case management system evaluation underway

Care Coordination Practice Council: New cross-continuum committee will integrate inpatient, ambulatory-based, and health plan case managers to improve communication and best practice sharing

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Resource Management Center-

Our UM Hub for 7 hospitals

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• At the access points of the hospitals, RNs assess patients to determine medical necessity and provide transition planning.

• The use of MCCM enables the RMC staff to seamlessly provide additional clinical information as needed or if a physician review is required.

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Access Coordinator

s

• Care Coordination Dyad – Nurse and Social Worker

• Team Approach – daily huddles• Coverage - 7 days per week• Plan of the Day /Plan of the Stay

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Hospital BasedCare

CoordinationTeam

Appropriate Social Work Referrals

• All placements: (SNF, NF, LTAC, Acute Rehab, Adult Home/Assisted Living, Shelters)– Ventilator– CVA with paralysis– Fractures/Replacements of Hips and Knees (if criteria

met)– Elderly / frail/ living alone / inadequate social support– Homeless– Psychiatric (suicidal, in need of acute psychiatric

hospitalization)• APS/CPS/ Domestic Violence• Patients/ family members in need of support and crisis

counseling due to traumatic injury and /or medical condition

• Patients experiencing Post-traumatic stress symptoms (nightmares, reliving events, depression, guilt)

• Maternal Health

Updated 3/12/20137

Freedom of Choice

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Request Form

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Vendor Policy

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ScopeExternal company data network connections to Sentara can create potential security exposures if not administered and managed correctly and consistently. These exposures may include non-approved methods of connection to the Sentara Healthcare network, the inability to shut down access in the event of a security breach, and exposure to hacking attempts. This standard applies to all vendors, including all personnel affiliated with vendors. When vendor connections do not meet all of the guidelines and requirements outlined in this document, they will be re-engineered or disconnected as needed.  Business JustificationRemote access into Sentara’s internal network will be approved based on business need and system availability. Appropriate justification would include, but not limited to, vendor support for a specific application or system.  Available TechnologiesSentara will only provide applications and access in accordance with the contract on file. The preferred technology for vendor remote access is metaframe connectivity. This would be accessed via the internet using a posted URL address. All vendor metaframe access will be authenticated (i.e., ID and password).

Inpatient or Outpatient??

Outpatient or Outpatient with Observation Services

CMS Guidelines

Everyone does it differently Very limited

Medicare Claims Processing Manual

Chapter 4; 290.1 (07-06-09)

Observation Services Defined

Well defined set of specific, clinically appropriate services, which include:

– Ongoing short term treatment;– Assessment, and – Reassessment…

Medicare Claims Processing Manual

Chapter 4; 290.1 (07-06-09)

Observation Services Defined

….before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Medicare Claims Processing Manual

Chapter 4; 290.1 (07-06-09)

• “Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision regarding admission or discharge.”

CMS 2014 Inpatient Prospective

Payment System (IPPS) Final Rule

Overview of IPPS 2 Midnight Rulefor Inpatients

• Published: August 19, 2013• Effective: Oct. 1, 2013• Applies to all Inpatient and

critical access hospitals • Inpatient psychiatric hospitals

excluded

17Sept.12, 2013

Physician Certification Requirements

• Authentication of the practitioner order• Reason for the Inpatient services/

treatment or diagnostic study; “Special or unusual services” the patient will receive

• The estimated time the patient will stay in the hospital

• Plans for post-hospital care, as appropriate

18Sept.12, 2013

Skilled Nursing Facility Placements

• Still requires 3 Inpatient Midnights-

no change• ED or Outpatient Observation

Midnights do not count towards SNF placements

19Sept.12, 2013

QUESTIONS?

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Contact Information

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Sentara Care Plex Care Coordination Manager: Quijuana Goodman 757-827-2371

Sentara Obici Care Coordination Interim Manager: Charlene Russell 757-934-4627

Sentara Healthcare: Sally Sekowski 757-455-7385Sherry Parker 757-455-7231

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