Road Map of Pain

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.
4

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
5

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.
6

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.
7

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.
8
  • 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.
9

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.
10
  • 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.
https://hcup-us.ahrq.gov/reports/statbriefs/sb304-readmissions-2016-2020.jsp