Discharge Planning Advisor-Postacute care gap sparks DP feedback
Knowledge of law, political action important
Discharge planners accustomed to moving patients out of the hospital into less expensive settings are finding that the momentum has changed. With the government tightening the reins on reimbursement for postacute care, the trend, it seems, is back to longer hospital stays for chronically ill patients, and many health care professionals are at a loss as to how to remedy the situation.
Solutions and stop-gap measures are surfacing, however, as providers seek to find the appropriate care setting for their patients.
"It seems like we have gone full circle," says Anne Llewellyn, RN, C, BPSHSA, CRRN, CCM, CEAC, owner of Professional Resources in Management Education in Miramar, FL. "The government has cut the [reimbursement] for postacute care since it was costing too much. Now we are back to longer stays for the more complicated patients since the postacute settings cannot make money on them."
Discharge planners and case managers throughout the country say they are getting more refusals from long-term, subacute, and home care services. Llewellyn and her partner, Kathleen Moreo, RNCm, BSN, BPSHSA, CCM, CDMS, CEAC, who also is president of the Little Rock, AR-based Case Management Society of America, heard from participants in the "Essentials of Case Management" course they taught recently that Medicare's new prospective payment system (PPS) is seriously influencing the way patients are shifted from acute to postacute care.
"Patients who are high-cost, such as those needing TPN [total parenteral nutrition], are too risky," says Simone Beliveau, RN, BSN, a case manager in Dover, ME. "The case manager will need to enhance his or her ability to access community resources and perform better resource management. Knowing the law and its limitations and possibilities will be important."
"I have vent patients who cannot be transferred due to the lack of facilities in our area," adds Lynne Jackson, RN, discharge planning coordinator at Maine Medical Center in Portland. "Patients remain in the hospital. Family support doesn't seem to exist to transition to home. We'll need to get better at educating families and being sensitive to family issues so we can move more patients from hospital to home."
Patients on long-term vents are also difficult to place in her area, as are those on dialysis, says Tina Davis, MS, CNS, senior director of continuum of care at Arnot Ogden Medical Center in Elmira, NY.
"We have a large dialysis population that goes on to be long-term care, and we can't get nursing homes to take those patients because they are expensive to take care of," Davis adds. "They have very expensive medications, and it is very difficult to place patients with such complex medication regimes."
Arnot Ogden has a 12-bed alternate level of care nursing unit where it cares for such patients until a bed is available at a skilled nursing facility, she says. "Sometimes they are with us for a year before we can get them placed."
Because Medicare will not pay for intravenous medications unless a patient is homebound, Davis notes, her hospital is filling the gap for patients who need that treatment. Otherwise, she says, such patients would have to stay in the hospital for six weeks. "We are providing a service through an infusion clinic where patients can come in once or twice a day [for IV medications]. If they need more than that, we have a discussion with the physician, who will, where clinically appropriate, change the [prescribed] antibiotic from one that has to be given several times a day — such as ampicillin — to one that can be given once or twice."
When there is such a gap in services, Davis says, her hospital typically tries to respond. Because of the lack of subacute beds in the community, for example, the institution is looking at opening its own subacute unit.
"A case manager will collect data on how many days any patient would meet subacute criteria," she says, "and record that date and the date the patient is discharged. We will collect 'potential subacute days' so we can identify the need. The size [of the unit] will be based on what we find."
As part of the study, the hospital also will look at whether the payment source will be there, Davis adds, "so the patient won't have to pay and the hospital doesn't get stuck with the bill."
It's particularly frustrating, she points out, that services Medicare does not fund often are the solutions that would save money in the long run by reducing hospital admissions and emergency department visits. (See related story, p. 91.) "We have patients that need home care and when they leave the hospital are all set up for that," Davis says, "but they can only have it as long as they are homebound or need a dressing change. If they don't meet those criteria, the agency has to discharge them."
For example, these patients still might need help in understanding the management of congestive heart failure, which could be provided through home nursing visits, she adds. "Those educational needs just aren't provided for."
To help bring those and other health care needs — including concerns about the PPS — to the forefront, suggests Llewellyn, case managers and discharge planners should get involved in the political process.
"This is an election year, and each case manager needs to understand where the candidates and other government officials stand on this issue," she says. "Case managers are seeing firsthand how the changes in the Balanced Budget Act of 1997 are affecting patients and the care they are getting. Each case manager, despite the setting, has seen the effects of these changes and needs to have a voice that brings the problems to the surface. We as case managers say we are advocates. This is one way we can put these words into action."
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