Lunch & Learn
Sentara Care Coordination
Sally Sekowski, RN, MSN, ACM
Director, Care Coordination
Sentara Healthcare
Sherry Parker, LCSW, ACM
Manager, Social Work Services
Sentara Healthcare
September 19, 2013
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A Vision of Change –
February 2011 the Journey Begins
Access Care
Coordinators
Resource
Management
Center
Continuum of
Care Providers
Our patients
Multi-disciplinary
Teams
Sentara Hospitals
VPMA’s/Physician
Advisors
Unit Based
Care Coordination
Team
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Inpatient Redesign First Step in Improving Ability to Support Broader Efforts
Multifaceted Case Management Approach at Sentara Healthcare
1
Crafting a Comprehensive Case Management Strategy
Phase II
Phase I
Resource Management:
Centralized corporate office
conducts utilization review,
discharge planning
Access Coordination:
Case managers embedded at all
points of patient access (e.g., ED,
OB, etc.) to ensure appropriate
level of care provided
©2012 THE ADVISORY BOARD COMPANY
Medical Necessity Reviews:
VPMA advisors, with support
from external agency, reviews
cases, interfaces with medical staff
Care Coordination Dyad
Model: Social worker and care
coordinator paired to improve
coordination of care; staffing
ratios re-evaluated to ensure
adequate support
Revitalized Multidisciplinary
Rounds: Representatives across
different clinical disciplines
collaborate to conduct joint
rounds and create a patientcentered
care plan1
Phase III
Enhanced Technology:
Case management system
evaluation underway
Post Acute Partnerships: Case
management leaders will collaborate
with post-acute care providers to
improve transitions, information
exchange, unnecessary transfers
Care Coordination Practice
Council: New cross-continuum
committee will integrate inpatient,
ambulatory-based, and health plan
case managers to improve
communication and best practice
sharing
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1) Sample staff included in rounds are physicians, nurses, physical therapists, nutritionists, etc.
Resource Management CenterOur UM Hub for 7 hospitals
Utilization
Management
Discharge
Facilitation
Compliance
and
Auditing
Resource
Staffing Pool
RMC
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Access Coordinators
• At the access points of the hospitals, RNs
assess patients to determine medical necessity
and provide transition planning.
• The use of MCCM enables the RMC staff to
seamlessly provide additional clinical
information as needed or if a physician review is
required.
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Hospital Based
Care Coordination
Team
• Care Coordination Dyad – Nurse and
Social Worker
• Team Approach – daily huddles
• Coverage - 7 days per week
• Plan of the Day /Plan of the Stay
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Appropriate Social Work Referrals
• All placements: (SNF, NF, LTAC, Acute Rehab, Adult Home/Assisted
Living, Shelters)
– Ventilator
– CVA with paralysis
– Fractures/Replacements of Hips and Knees (if criteria met)
– Elderly / frail/ living alone / inadequate social support
– Homeless
– Psychiatric (suicidal, in need of acute psychiatric hospitalization)
• APS/CPS/ Domestic Violence
• Patients/ family members in need of support and crisis counseling
due to traumatic injury and /or medical condition
• Patients experiencing Post-traumatic stress symptoms
(nightmares, reliving events, depression, guilt)
• Maternal Health
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Updated 3/12/2013
Freedom of Choice
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Request Form
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Vendor Policy
Scope
External company data network connections to Sentara can create potential security exposures if not
administered and managed correctly and consistently. These exposures may include non-approved methods
of connection to the Sentara Healthcare network, the inability to shut down access in the event of a security
breach, and exposure to hacking attempts. This standard applies to all vendors, including all personnel
affiliated with vendors.
When vendor connections do not meet all of the guidelines and requirements outlined in this document, they
will be re-engineered or disconnected as needed.
Business Justification
Remote access into Sentara’s internal network will be approved based on business need and system
availability. Appropriate justification would include, but not limited to, vendor support for a specific
application or system.
Available Technologies
Sentara will only provide applications and access in accordance with the contract on file. The preferred
technology for vendor remote access is metaframe connectivity. This would be accessed via the internet using
a posted URL address. All vendor metaframe access will be authenticated (i.e., ID and password).
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Inpatient or Outpatient??
Outpatient or
Outpatient with Observation Services
Outpatient
Observation
Medicare
CMS
Guidelines
Commercial
Everyone does it
differently
Medicaid
Very limited
Medicare Claims Processing Manual
Chapter 4; 290.1 (07-06-09)
Observation Services Defined
Well defined set of specific, clinically
appropriate services, which include:
– Ongoing short term treatment;
– Assessment, and
– Reassessment…
Medicare Claims Processing Manual
Chapter 4; 290.1 (07-06-09)
Observation Services Defined
….before a decision can be made
regarding whether patients will require
further treatment as hospital inpatients or
if they are able to be discharged from the
hospital.
Medicare Claims Processing Manual
Chapter 4; 290.1 (07-06-09)
• “Observation services are commonly
ordered for patients who present to the
emergency department and who then
require a significant period of treatment
or monitoring in order to make a decision
regarding admission or discharge.”
CMS 2014 Inpatient Prospective
Payment System (IPPS) Final Rule
Overview of IPPS 2 Midnight Rule
for Inpatients
• Published: August 19, 2013
• Effective: Oct. 1, 2013
• Applies to all Inpatient and critical access
hospitals
• Inpatient psychiatric hospitals excluded
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Sept.12, 2013
Physician Certification
Requirements
• Authentication of the practitioner order
• Reason for the Inpatient services/ treatment or
diagnostic study; “Special or unusual services”
the patient will receive
• The estimated time the patient will stay in the
hospital
• Plans for post-hospital care, as appropriate
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Sept.12, 2013
Skilled Nursing Facility
Placements
• Still requires 3 Inpatient Midnightsno change
• ED or Outpatient Observation Midnights
do not count towards SNF placements
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Sept.12, 2013
QUESTIONS?
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Contact Information
Sentara Care Plex Care Coordination Manager:
Quijuana Goodman 757-827-2371
Sentara Obici Care Coordination Interim Manager:
Charlene Russell 757-934-4627
Sentara Healthcare:
Sally Sekowski 757-455-7385
Sherry Parker 757-455-7231
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