System Approach for the Financial and Clinical Oversight for Post Acute Charity Patients “Who’s Minding the Candy Store?” Patricia J Davis MHA, RN, ACM • Elaine Moberley MSN, RN, ACM, CCM Inova Health System Falls Church, Virginia
Introduction Escalating healthcare costs, decreasing insurance coverage despite the ACA, increasing numbers of indigent, undocumented, and underinsured community members has created a challenge for healthcare providers. Safe discharge planning requirements addressed in the CMS Conditions of Participation must occur and be documented. Often finding an appropriate lower level of care for uninsured or underfunded patients can prove to be futile. Many of these patients remain In the acute inpatient facility even when medically ready for discharge. Some hospitals discharge these patients with referrals to community services and hope for the best, while others pay for lower levels of care with no financial end in sight. Inova is a non-profit healthcare provider that brings healthcare, education, and wellness programs to the Northern Virginia and DC metro area, The services are offered regardless of ability to pay which translates to millions of dollars in charity care each year. Inova has 5 acute facilities, including a Level 1 Trauma Center, with a total of 1,814 beds.
Methods • Identified patients financially subsidized by Inova in SNF, LTAC and ALF by means of claims search • Intensive patient assessment by case manager to identify levels and cost of care to determine appropriateness • Meeting with case management directors at each acute care hospital to present new work process and claims management • Met with case management staff to explain new work process and expectations • Created database in EPIC (EMR) to identify current patients with LOS>5 days • Set up meetings with key members of contracted post-acute facilities to establish onsite discharge meetings for review, continued stay approvals, and claims process • Created a notification of assistance form for patients and families in 9 languages • Created vendor agreements around non-urgent transportation, DME, and home health • Outreach to community resources to introduce and partner with them for transitioning patients • Instituted monthly financial reporting
A team was created consisting of two nurse care managers, a financial manager, and a clerical assistant who were to initiate a central reporting and monitoring division. This team oversaw unfunded patients that require continued medical care in a post-acute setting. The team manages length of stay in SNFs, LTACHs, and ALFs. They assist with the transitioning of patients to lower level of care including home settings. Hospital Directors of Case Management and CFO’s are provided with monthly accruals for budgeting purposes. The development of network ties to community providers; physicians, home health agencies, infusion companies and others has proven to be an asset in managing the continuum of care for charity patients. Financial stewardship, accountability, and oversight with standards of work processes has helped define this team’s mission. The picking and choosing of services that the Inova Health System will pay for, like candy in a candy store will no longer be a sweet alternative.
Healthcare is volatile, challenging , and costly. What happens today is out of sync tomorrow. Patients and families want and expect more and more regardless of cost or payer source. When we started the program, we wanted to determine if costs could be controlled without sacrificing quality. This could be achieved by closely monitoring those patients placed in SNFs, ALFs, and LTACs under our “system dollars”. Identifying where the dollars were being spent on current long term patients and determining the most appropriate care setting was the first step. Transitioning those long term patients to the appropriate care setting allowed us to better determine costs, care needs, and length of stay. A significant savings was appreciated after the first year. Educating staff in the acute care setting also resulted in a decrease in the number of individuals referred for “system funding”. Many staff members were unaware of the cost to place patients in LTAC vs SNF, what was reimbursable if Medicaid was approved, why it was necessary to “turn over every leaf” for options for discharge, and the need to complete the necessary paperwork for long term placement. Meeting with our community partners to better understand what services they can provide and for them to understand what we at Inova could provide was phenomenal information. Sharing and collaborating with the community partners has created a more collegial relationship. Contracting SNFs, ALFs and LTACs to prevent the back and forth signing of “single payor agreements” also created a smoother transition upon discharge. Reimbursement and reporting expectations are known prior to acceptance. Establishing face to face visits and conference calls also contributed to a smoother discharge process. By attending family Goals of Care meetings at the facilities, our team was better able to identify barriers to discharge unrealistic expectations for discharge, and identify opportunities for a successful transition to the next level of care.
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Goals • Identification of those patients transitioned to SNF, LTAC, ALF post-acute hospitalization financially subsidized by “SYSTEM FUNDING”. • Determine if centralized coordination of care, financial management and individualized discharge planning could reduce overall costs in the post-acute phase. • Mitigate barriers to discharge from post-acute level of care through intensive coordination and partnerships with community partners and healthcare vendors.
Summary
Data collected for 477 unique SCM patients with any facility placement in 2016-2018 – 12 in a facility for the entire 36 month time period and 8 for 12+ months Over 50% decrease in SCM facility patient census and spending from January-June 2016 to January-June 2017 (167 to 79 patients and $3.9 million to $1.8 million) o o o o
# Highest cost patients ($50K in 6 months) fell from 22 ($1.7 million) to 7 ($460K) # Moderately high cost patients ($25K-$49K in 6 months) fell from 31 ($1.2 million) to 20 ($700K) $1 million less LTAC Medicaid conversions; transitions to lower level of care; fewer hospital facility placements
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SCM facility patient census increased to 103 in July-December 2017 and spend to $2.3 million
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Increase in patient complexity January-June 2018 – 101 patients with $2.9 million spend
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13 Highest cost ($860K) and 21 moderately high cost ($730K) 20 highest cost ($1.5 million) and 22 moderately high cost ($801K)
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By July-December 2018, census managed down to 74 patients with $2 million spend; level of patient complexity continues
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99 Patients ultimately received Medicaid – 23 patients with no financial liability $1.3 million collected in refunds (44 patients) after Medicaid conversion
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14 highest cost ($860K) and 20 moderately high cost ($710K)
References • Centers for Medicare and Medicaid Services. (n.d.) Condition of participation: Discharge Planning (Section 42CFR ss 482.43). Washington, DC Government Printing Office. • Centers for Medicare and Medicaid Services. (n.d) Condition of participation: Utilization review (Section 42CFS ss 482.30). Washington, DC Government Printing Office. • Inova at-a-Glance 2018 Available at http:inovanet.net.inova.org/upload/docs/about_inova/inova%20at%20a%20glance_04%202018.pdf • Inova Clinical Documents. Case Management “Notification of Post-Hospitalization Payment Assistance” • Inova Case Management Policies: System Case Management Services. 06/09/2015
The fluctuating cost of care impacts the amount of money that is spent. We cannot always predict patient mix or severity. We are better able to predict potential post-acute cost of care which can include length of stay in extended facilities and additional transitional care needs. The Inova Health System will continue “to seek every opportunity to meet the unique needs of each person we are privileged to serve- every time, every touch”. Our system offers a variety of options for post-acute care, no different than options in a candy store. Should I purchase chocolate versus gummy bears or should we offer home care versus skilled care at a SNF? Healthcare is expensive and our health system provides generous amounts of charity care, but financial stewardship is necessary. By better understanding where our dollars are spent allows for the Inova Health System to continue assisting those in need of care.
Where do we go? • Continue monitoring and educating Case Managers in the acute care setting • Exploring and expanding partnerships with our Community agencies • Expand the SCM program to include Home Health services, dialysis, transportation, and DME • Review and update contracts with extended care facilities to reflect changing regulatory mandates • Pursue potential recipients for the expanded Medicaid coverage in Virginia