1
Boarding patients in your Emergency Department is bad for
- Patient Satisfaction
- Length of stay
- Outcomes
- Mortality
Take action to reduce boarded hours in your emergency departments by actively managing hospital stays early on and reducing questionable and unnecessary hospitalizations.
- Habib, H., & Sudaryo, M. K. (2023). Association Between the Emergency Department Length of Stay and in-Hospital Mortality: A Retrospective Cohort Study. Open Access Emergency Medicine : OAEM, 15, 313–323.
- Roussel, M., Teissandier, D., Yordanov, Y., Balen, F., Noizet, M., Tazarourte, K., Bloom, B., Catoire, P., Berard, L., Cachanado, M., Simon, T., Laribi, S., & Freund, Y. (2023). Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Internal Medicine, 183(12), 1378–1385.
- Loke, D. E., Green, K. A., Wessling, E. G., Stulpin, E. T., & Fant, A. L. (2023). Clinicians’ Insights on Emergency Department Boarding: An Explanatory Mixed Methods Study Evaluating Patient Care and Clinician Well-Being. Joint Commission Journal on Quality and Patient Safety, 49(12), 663–670.
2
Do you ever have patients arrive for elective procedures only to discover that:
- Their authorization is for the incorrect insurance?
- They are authorized for a different procedure?
- The level of care is incorrect?
- There is a procedure code error in the authorization?
- Create work-flows that reduce the likelihood of these process failures. Task the correct team member with reviewing pre-service cases at the right time to prevent these last-minute crises.
- Train a medical director to adjudicate and resolve those last-minute decisions that require balancing the fiduciary needs of the institution with the medical needs of the patient.
3
The medical note is the source of all information used in both clinical decision-making and in all the meta-processes such as authorizations, coding, billing, quality measures, mortality index, risk adjustment, and legal adjudications.
- Do you know how to engage your providers to impact documentation in a meaningful manner?
- Have you been successful in changing charting habits?
- Are your chart notes more noise than signal?
- Engage all stakeholders into documentation improvement
- Create a culture of ongoing improvement and expect self-sustaining change.
- Aghajan Y, Codner CA, Martin P, Prakash S, Mendoza R, Jones DL, Molyneaux BJ. Optimizing Neuroscience Mortality: A Collaborative Approach to Documentation Improvement. Neurol Clin Pract. 2024 Aug;14(4):e200315.
- Gay LJ, Lin D, Colah Z, Raynaldo G. Inpatient Coding System and Opportunities for Documentation Optimization: An Interactive Session for Internal Medicine Residents. MedEdPORTAL. 2022 Feb 28;18:11219. doi: 10.15766/ mep_2374-8265.11219.
- Seligson MT, Lyden SP, Caputo FJ, Kirksey L, Rowse JW, Smolock CJ. Improving clinical documentation of evaluation and management care and patient acuity improves reimbursement as well as quality metrics. J Vasc Surg. 2021 Dec;74(6):2055-2062.
Length of stay impacts the cost of care more than any other single factor and reducing LOS is revenue-neutral for DRG based hospital admissions.
- Have you been as effective as you wished to reduce LOS to your target goals?
- Have LOS been refusing to budge?
- Are you pouring resources and spending valuable provider time on meetings attempting to influence LOS only to find minimal changes?
- It’s hard to impossible to impact LOS by intervening at the end of the hospital stay.
- The trajectory of the patient in the hospital in determined early on by the decisions made in the first 24 to 36 hours
- Ask me about an innovative approach to LOS management using prospective targets and alternative documentation methods
Level of care determinations impact your observation ratio, result in inpatient denials, impact patient benefits, and alter a variety of other hospital indices. Getting these right as frequently as possible and as early as possible is paramount. Doing so with minimal resources is key.
- Are you playing tug of war with your payers over LOC? Authorization requests; denials; peer-2-peer; denial; post claim appeal?
- This is a no-win strategy. No matter how hard you try and push, your payers will push back. This is a zero-sum game.
- Stop cost-shifting, start creating value. Stop cutting costs, start cutting waste. Do the right thing and get paid for it.
Denials are an inevitable part of inpatient authorization requests.
- Are you launching requests without supporting documentation?
- Do your clinical notes truly reflect the acuity of the patient’s illness?
- Do you have a learning loop to improve your processes?
- If you use a vendor for your utilization review process, are you satisfied with the oversight, productivity, and outcomes you are receiving?
- Consider a third-party audit and evaluation to determine if you are receiving the services you contracted for and are obtaining the outcomes you are paying for.
- If your UR process is in-house, are your medical directors high functioning and self-improving? Are you reporting the data needed to understand the quality of your work?
- Consider an assessment of your operations, the relationship between medical directors and review nurses, and the operational daily work-flows.
Post-claim denials are difficult to manage, require opening old books, and are difficult to appeal.
- Are you able to triage your denials and decide when to appeal and when to concede?
- Are you prepared to argue high dollar Medicare cases at the ALJ level?
- Do you have a feedback loop to improve documentation that will decrease future denials?
- Consider auditing your work-flow to determine if improvements are possible
- Review your outcomes to set new goals and targets
- Coach and mentor your nurses and physicians to be more effective in front of and after the denials.
- Are you having a problem discharging patients in a timely?
- Are the SNFs giving you grief with delays in accepting your discharged patients?
- Are early morning discharges an impossible aspiration?
- Anticipate your SNF requirements early enough to secure a bed
- Reduce your need on SNF discharges and send more patients home
- Anticipate discharges well in advance.
Transitioning your patient from inpatient to ambulatory is traditionally a weak link in the system, a source of error and an opportunity for readmission.
- Are you recycling the same failed processes to hand off your patients to their PCPs?
- Are you failing to correctly reconcile medications on the way in and on the way out?
- Are patients getting readmitted before having a single post-acute office visit?
Invest in what works
Pick the low-hanging fruit
- Cordato NJ, Kearns M, Smerdely P, Seeher KM, Gardiner MD, Brodaty H. Management of Nursing Home Residents Following Acute Hospitalization: Efficacy of the “Regular Early Assessment Post-Discharge (REAP)” Intervention. J Am Med Dir Assoc. 2018 Mar;19(3):276.e11-276.e19.
- Birtwell K, Planner C, Hodkinson A, Hall A, Giles S, Campbell S, Tyler N, Panagioti M, Daker-White G. Transitional Care Interventions for Older Residents of Long-term Care Facilities: A Systematic Review and Meta-analysis. JAMA Netw Open. 2022 May 2;5(5):e2210192.
- Balqis-Ali NZ, Jawahir S, Chan YM, Lim AW, Azlan UW, Shaffie SSM, Fun WH, Lee SWH. The impact of long-term care interventions on healthcare utilisation among older persons: a scoping review of reviews. BMC Geriatr. 2024 Jun 3;24(1):484.
- Readmissions is a multi-headed monster, notoriously difficult to slay.
- Readmissions are bad for patients, bad for providers, and bad for payers – everybody loses.
- Dare to get out of the rut.
- Think differently.
- Impact readmissions with action on the day of admission.