Changing health care environment can make discharge planning a juggling act
Patients have more out-of-pocket expenses, changing benefits
It’s no longer enough for case managers to know where patients are going after discharge. Now they have to know each patient’s benefits as soon after admission as possible and be aware of what the benefits will and won’t cover.
If you are a typical hospital case manager, you probably encounter the following problems more frequently than ever before:
- A patient who is shocked by the out-of-pocket expenses he’s going to incur because his health plan no longer covers everything and questions you closely about your discharge plan.
- A patient with no pharmacy benefit who is turned down by a nursing home because of the expense of her post-acute care.
- Someone who is ready to be discharged with home health care but has no home health benefit and can’t afford to cover the cost.
Today more than ever, hospital case managers have to do a lot of juggling to see that their patients get the care they need after discharge.
"We thought we were being proactive when we did discharge planning. But now, we’re going to have to go more in depth when we do our assessments and focus on the patient’s benefits early on," says Beverly Cunningham, RN, MS, director of case management at Medical City Dallas Hospital.
Today’s workers often have more financial responsibility than in recent years for their health care costs.
In some cases, their employer is moving toward a defined benefit program and expecting the employee to pick up more out-of-pocket expenses. Or they may give people the choice between two insurance plans, an HMO and a PPO, and expect the employee to pick up the extra cost for copay or premium costs if it exceeds a certain amount.
Copay amounts and deductibles are increasing. Medicare and Medicaid no longer cover some of the benefits they covered a few years ago. The number of unemployed, uninsured, and underinsured patients is increasing as well.
Even people who have a full-time job with insurance coverage are going to have to pay more out of pocket, adds Patrice L. Spath, BA, RHIT, owner of Brown-Spath and Associates, a Forest Grove, OR, firm specializing in educational programs on quality management, utilization control, and patient safety issues.
That means the dynamics between the patient and caregivers are changing as people have to pay more out of pocket for health care.
"Case managers are dealing with people who have no money to pay out-of-pocket expenses and who are looking for community resources. They’re also dealing with people who have money to pay out of pocket but will be very questioning about whether the money they are paying will be used appropriately," Spath adds.
The complexity of cases and the number of patients with complex needs are growing all the time, says Jackie Birmingham, RN, MS, CMAC, vice president of clinical design for Curaspan, a provider of connectivity and network management across the post-acute continuum.
And it’s getting harder for case managers to know what is covered for a particular patient. For instance, Birmingham teaches a class for case managers at a large insurer that writes innumerable variations of coverage.
In today’s health care environment, case managers must go back to focusing on discharge planning, Birmingham asserts.
"When hospitals started calling discharge planning case management, a lot of the skill and attention previously given to discharge planning went on the back burner because utilization review takes up so much time," she says.
Now, hospital case managers often have to call the insurance company to get an extra day for the patient or report what is happening with the patient every day. As a result, they have little time for discharge planning, but it’s a job that is more necessary than ever if case managers are going to be advocates for their patients.
Case managers are well advised to take a proactive approach and weave discharge-planning needs into utilization management and utilization review.
Case managers should begin a dialogue with a patient’s managed care company on admission or prior to admission if it’s a planned admission, recommends Toni Cesta, PhD, RN, FAAN, director of case management for Saint Vincent’s Hospital and Medical Center in New York City. "When you get into a situation when a benefit is not available, it helps to have a working relationship with a managed care case manager," she says. Case managers should begin a dialogue with a patient’s managed care company on admission or prior to admission if it’s a planned admission, Cesta says.
Most managed care companies have case managers who will work with you on discharge planning to determine what benefit the patient does or does not have.
After that is established, the two of you should work together toward a safe discharge, Cesta says.
For instance, if a patient is coming in for a hip replacement and is likely to need rehabilitation, the case manager should start working on that benefit before the surgery takes place.
Many managed care companies no longer pay for acute rehab following orthopedic surgery. If this is the case, the case manager should start to plan for a subacute admission or home care.
When you have a question about the interpretation of benefits, call the case manager at the payer and verify whether what the patient needs is covered. If it’s not, ask for an individual exception.
The patients most at risk and those who need the most discharge planning are those who are admitted through the emergency department (ED), Birmingham points out.
Most of the time, these are patients who are uninsured and don’t go to the physician because they’ll have to pay. They know that the hospital ED can’t turn them away, so they count on the hospital to give them the care they need.
They wait until they are so sick they end up in the ED. Those at the greatest risk in many cases also are related to the greatest financial risk. Sometimes, they are Medicare patients whose physicians have stopped taking Medicare. They are so sick that the hospital has no choice but to admit them.
If a case manager believes that the patient cannot be discharged safely, the hospital has no choice but to keep the patient.
"It’s all in the definition of what is safe. What constitutes a safe discharge is often a nebulous thing," Birmingham says.
Some components of a safe discharge are:
- The patient knows where to get medical care and knows the signs of complications from the illness or injury.
- The patient has a prescription and the supplies he or she needs.
- The patient knows how to take care of him- or herself and has been instructed in things such as wound care and physical activity.
In some cases, post-acute services may not be available for the patient, Cesta notes. "In New York, we can get emergency Medicaid for a patient in the hospital but can’t get Medicaid for a patient in the community. We have patients who can be discharged but need continuing care with home health. If there is no free care in the community, the burden shifts back to the hospital," she says.
In many cases, hospitals end up keeping patients longer than they need to stay because they can’t safely discharge them.
"For case managers, the discharge planning function means that we are responsible for providing a safe and appropriate discharge plan. When there is a lack of service for continuity of care, we cannot discharge the patient and we won’t discharge the patient, so the hospital absorbs the cost," Cesta says.
Its no longer enough for case managers to know where patients are going after discharge. Now they have to know each patients benefits as soon after admission as possible and be aware of what the benefits will and wont cover.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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