Management Strategies for High
Risk Patients
03/14/15
Objectives
• Describe patient and situation types that should be
escalated for early intervention and risk mitigation
• Identify key disciplines for an interdisciplinary
approach to identifying and managing high risk
patient situations
• Define escalation and communication strategies to
mobilize systems and resources to manage high risk
patient situations.
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Sometimes You Get Really Stuck…..
The Urban Legend
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High Risk Early Escalation Triggers
Potential/Actual Complex Condition
Disabling/Life Limiting Condition
Multiple Specialty Care Needs
High Cost Medications/Outpatient Needs
AND
Barriers to Discharge
Patient and Family Limitations/Issues
Self-Pay/ Uninsurable
Limited Insurance Coverage/High Co-Pays
OR
Refuses Discharge Plan
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Legal/Regulatory Considerations
• CMS Medicare Requirements
• 42 CFR Conditions of Participation
• State Requirements
• Virginia Hospital Provider Manual
• Follows Federal Regulations
• Joint Commission Accreditation Standards
• Standard RI.01.02.01: The hospital respects the patient's right to participate in
decisions about his or her care, treatment, and services.
• Note: For hospitals that use Joint Commission accreditation for deemed status purposes:
This right is not to be construed as a mechanism to demand the provision of treatment
or services deemed medically unnecessary or inappropriate.
• Standard PC.04.01.03:
The hospital discharges or transfers the patient based on
his or her assessed needs and the organization’s ability to meet those needs.
• For hospitals that use Joint Commission accreditation for deemed status purposes and have
swing beds used for long term care: The written notice before transfer or discharge specified in
the CoP from 42 CFR 483.12(a)(4)
• Standard PC.04.01.05: Before the organization discharges or transfers a
patient, it informs and educates the patient about his or her follow-up care, treatment, or
services
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Medicare Provider Regulations 42 CFR §412.42
Also Information in 42 CFR §405, 422, and 489
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Virginia Medicaid Provider Manual; Chapter V
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High Risk Process
Tiered process for timely review and escalation
Level I
Level II
Level III
Ad Hoc Interdisciplinary Team Meeting
Leadership High Risk Meeting
CEO Meeting
Goals of High Risk Process:
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Ensure legal/regulatory requirements are met
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Appropriate Transfer of Care and/or Discharge
Facilitate complicated care decisions
Maintain respectful patient/family engagement
Achieve clinical outcomes
Mitigate financial losses
Level I: Ad Hoc High Risk Team Meeting
Interdisciplinary Team
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Case Management Leadership
Physician Advisor
Social Work Leadership
Financial and Business Operations Leadership
Corporate Counsel
Case Manager
Social Worker
Attending Physician/Subspecialist Consultants
Nursing
Medicaid Intermediary As Indicated
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Level II: Leadership High Risk Team Meeting
Supports Ad Hoc Team with decision making,
allocation of resources, and work with external
agents only if needed:
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Chief Medical Officer
Chief Nursing Officer
Chief Financial Officer
Chief Legal Officer
Chief Operating Officer
Chief Public Affairs Officer
Chief Quality Officer
Defined Escalation Process
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SBAR E-Mail Sent to Ad Hoc Team and High Risk Team
Meeting When Clinical Team Available
Phone Access for Non-Clinical Providers
Case Management Facilitates Meeting
Action Steps Outlined at Meeting
Follow-up E-Mail Sent After Meeting
All Escalated Cases Tracked
Weekly Long LOS Rounds for Continued Tracking
Case Study: SBAR
S: 21 year old with Duchenne’s Muscular Dystrophy admitted on 11/29/14
with respiratory distress. Patient stable for discharge since 2/16/15 but
placement limited due to age, tracheotomy, CPAP, Medicaid, and family.
STM LTC has accepted the patient for transfer tomorrow but now Disability
Law Center and family are raising last minute concerns about the transfer.
Medicaid has denied all PICU days for past 14 days.
B: Patient admitted 3 days before move into assisted living facility. Trach has
disqualified him from this facility. Family unable to care for patient in their
homes. Initial plan was SNF placement but patient medically appropriate for
custodial care. A private individual and group home were options, but state
refused funding. The placement at STM is approved by Medicaid but family
cites low CMS ratings. Other facilities are further away. Team now in
disagreement about discharge plan.
A: 21 year with Medicaid denial has disposition plan being challenged by the
Disability Law Center and family on the day prior to transfer.
R: High Risk Meeting Needed to make sure the entire team is on the same
page with patient transfer.
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Case Study: Follow-Up E-Mail
Today we had a meeting on the discharge plan. The plans below are
in the order of the patient’s preference:
1. Discharge to Private Home with DDA Funding: The Disabilities
Lawyer met with state yesterday and will hear back today. If he gets
accepted he would be discharged Monday when 16 hours of nursing
and home equipment can be in place. Case Management is working
with agency to get PDN nurse staffing and equipment.
2. Discharge to LTC: IB in City Farther Away has accepted the patient
and is the highest rated facility (4/5). They can accept the patient
tomorrow (Friday) if the DDA funding does not come through.
Social Work and Case Management will meet with the patient
together today to review the above plan with him, and then follow-up
with his family. They will keep us apprised of any barriers to discharge
and any developments.
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Case Study: Next…..
The state did not make a decision yesterday and is
planning to meet with patient next week.
Plan to schedule transfer to IB today as that was
patient’s first choice based on CMS rating. It is less
convenient for the family.
The expectation is this will be a temporary
inconvenience as longer term options explored.
Disability Lawyer on board with plan.
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Case Study: Team Conflict
Social Worker convinced patient and family to refuse
discharge until permanent housing arranged
Patient and family also refused to have further
communication with Case Manager
Team members divided on transfer
Second High Risk Meeting to openly address
conflicting view points
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Follow-up
Thanks to everyone for meeting with the family and
the patient to present the discharge plan in a positive
win-win fashion
The patient and family have agreed to the transfer
which will occur at 5:00 p.m.
The team will be meeting to debrief on this situation to
make the high risk process work better in the future
High Risk Leadership Would Have Been Next Step!
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Data Tracking
High Risk CY'14
# HR Cases
44
Total Charges
$15,732,046.69
Payment
4,055,150.96
% Recovered*
26%
* 3 cases pending
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DataTracking
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Case Tracking
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Focus On All Modes of Entry: Ambulatory
The following patient submitted an application for charity and
will qualify. Can you please review and let me know if there is
any high risk before moving forward.
Case Manager Assessment
This 17 year old Guatemalan patient was seen in Eye Clinic in
Sept 2014 and diagnosed with keratoconus. According to the
clinic note she will probably need a hard contact lens for the
affected eye. I am unsure that the child has a PCP. Will work
with Community Services on resources for contact lens and
reach out to family to arrange a PCP.
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Focus On All Modes of Entry: Peri-Op
Patient is schedule to go to OR tomorrow 3/03, patient’s FIC
pending and an estimate of charges has been attached, Mother
has been informed of the estimate amount.
Case Manager Assessment
The closed reduction nasal fracture for this 16 year old can be
approved. Has the FAP been approved as this is unclear? The
patient was seen in the ED after a volley ball injury. The patient
lives in Arlington, VA. He will need follow up in the clinic post
procedure. Patient has PCP. There is no added follow-up
needed.
FIC Response
The FAP has been approved at 100%.
Focus On All Modes of Entry: Emergency Department
S- 11 year old uninsured from Liberia admitted from ED with left orbital
mass. Patient is not eligible for charity and it is unclear what post discharge care
needs will be.
B- Patient presented in ED after arriving in area from West Africa on 12/14/14. Family
reports eye injury 2 years ago that has grown progressively larger and obstructing
vision in left eye for last 8 months. Patient went to OR on 12/14 for removal of
mass. No operative note available at this time—unclear if hemangioma or tumor. It’s
unclear what the post-discharge care needs will be.
Social: Mother and daughter speak Krio and plan to return to their country. It’s
assumed they have a Visitor’s Visa which may disqualify them from Emergency
Medicaid.
A - Patient at risk for not being able to receive care needed and CN at financial risk.
R- Obtain input from Ophthalmology and convene High Risk meeting to discuss next
steps.
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Out of Area
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Focus On All Modes of Entry: Out of Area
From Clinic to Out of Area Team
11 year old neuro-oncology patient enrolled in a highly restricted COG study
for treatment has MA Medicaid with Pilgrim Health Insurance. Study only
available here at CNMC. Patient having MRI today (not covered by study)
and will return next week for therapy (covered by study). I requested clinic
get authorization if there are any services not covered by study but it was
denied as we are out of state.
From Case Management to Contracting
Here is the information. I would argue for an LOA as the patient is in a very
limited clinical trial where there is no in sate provider. We will not bill for
anything related to the clinical trial but we do need to bill for routine care
and services while she is here. So far it is the MRIs which are needed here to
gauge the response to therapy.
Outcome:
LOA Signed
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Critical for Success
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Compliance with Regulatory Requirements
Escalation Process/Triggers
Early Escalation for Discharge Barriers
Rapid Response
Role Accountabilities
Support and Resolve Team Conflict
Respect Family/Patient Requests and Concerns
Good Relationships with Payers and Providers
Upper Leadership Support