And now I would like to introduce our speaker to get us started with part two. Dr. Tony Sesta is a founding partner of Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and on-site support for leadership and staff. Dr. Sesta has been active in the research and development of case management for over 25 years, and her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations with measures of patient satisfaction, quality of life, and short- and long-term clinical perceptions and outcomes. We are so thankful that you're back here with us this morning, Dr. Sesta, to kick off part two for us. Hey, thanks, Lindsay. Hey, everybody, welcome back. Lindsay and I were just chatting before we came on, and here we are in the middle of the holiday season, and you troopers, Lindsay, they're troopers. They're all back with us again today. They really are. And I really do appreciate that. And for those of you that will be listening later, that's great, too. So we are on to module two today, and today is going to bring back, for those of you who may have been in our basic boot camp, we're going to bring back some of the concepts we talked about regarding utilization management and meld those with the two-midnight rule as well as our new topic, access point case management. So it doesn't matter if you work in the ED or you don't work in the ED, because if you don't have a good front-end process, it's going to impact you if you're on the unit. If you're a unit-based case manager, it's going to impact you, as we like to say, downstream anyway. So everything begins at the moment in which that patient walks or is rolled into your hospital. So we're going to kind of commingle these concepts today. So as you may remember way back in basic boot camp, we talked about the transition of case management from a community-based model into the hospitals, and that was around 1985, 1986. And then back then, you know, we didn't have a lot of managed care penetration yet nationally. There were pockets of high-volume managed care in some states, but generally speaking, managed care hadn't really proliferated yet. Oh, I said proliferated without a problem in the morning. That was good. So we didn't see a lot of that. And Medicare didn't have a lot of the rules that we're all dealing with today, like the two-midnight rule as an example. So those early case management models really weren't looking at these routes of entry. There really wasn't a great need to do so. But as regulatory issues changed, as we saw more and more managed care, we began to realize that we needed to look at our access points. We needed to gatekeep those routes of entry. And if not, again, we're going to have those issues downstream that we're going to talk about today. And what you don't want to have to do is a lot of condition code 44s or provider liables because that just sets up a lot more work that you can avoid if you do everything right from the beginning. So just, again, to sort of set the stage for us, the Agency for Healthcare Research and Quality has given us some statistics. So millions of people are visiting emergency rooms. And most of those, the vast majority, come from their private residences. But another 3.5 million come from nursing homes or other residences. So most of us come from home when we go to an emergency department. More than 9 in 10 of those ED visits in 2020 were related to acute conditions. And half of these also involved chronic conditions. So sometimes you'll hear the term, you know, acute on chronics of somebody with an exacerbation of a chronic condition. Injuries comprised one in four ED visits. ED visits for people between the ages of 65 and 74 have almost doubled between 2005 and 2020. And that's from the Centers for Disease Control and Prevention. So it's interesting, as we're seeing more seniors moving into Medicare Advantage plans, and yet we are also seeing our seniors going to emergency departments. In the Annals of Internal Medicine, they said that about 10% of the population under age 65 visited the ED for reasons that were considered non-urgent, defined as those for which the patient should be seen within two hours to 24 hours of arrival. So there's your definition if you were wondering what non-urgent really means. Because it does sound kind of subjective when you say this is a non-urgent issue. If the patient can clinically and safely be seen between two hours and 24, that's sort of your non-urgent time frame. Under two hours would be considered urgent or an emergency. So I mean, that's not something the lay public is necessarily going to be concerned with, those time frames, but just for our purposes today. So I know I'm a little bit older, but some of you, some of you may remember the old Dave Letterman show. And in the Dave Letterman show, he had the top 10 reasons for whatever it was. So today we're going to talk about the top 10 reasons why you must have ED case management. Now I'm hoping that a lot of you currently do have ED case management of some sort. But again, just as we've talked about many other topics, there are best practices for ED case management as well. So you need to have it, and you need to have it set up in the most useful way, which we'll talk about later. So number 10, of course you want to assign the appropriate level of care from the patient's point of entry. So again, we don't want to have to back out of an acute admission and so forth. We want to get it right from the beginning. The RAC, the recovery audit contractors, look at the levels of care. Reduction and readmissions. Again, you want to gatekeep those readmissions. Improvement in inpatient throughput. So if you think about the emergency department episode, if you will, as a throughput or patient flow opportunity, then you can think about how I can optimize the time that that patient is spending in that emergency department, particularly if they're going to be admitted to the hospital. And again, that's one of the roles of our ED case managers. Reduce the need to use code 44, as I just mentioned. Again, that's sort of a corrective action that you take later that you want to try to avoid. Number five, ensure compliance with medical necessity. I mean, that has two prongs to it. Your managed care companies are looking at that. Those admission denials are, I think they're still the number one largest group of denials, those admission medical necessity denials. So again, you want to get that right from the beginning. And then Medicare expects us to self-deny. So from both vantage points, both large payer groups, you want to make sure you're getting it right. Number four, reduce commercial admission denials. I guess I just said that one. Number three, manage observation patients. Now I'm not an advocate for observation being in the ED or next to the ED. Those were the early days of observation when folks kind of just had them considered kind of part of the ED, which they're really not. They're really a discrete group of outpatients, and they should be managed as such. But you want to get them in observation from the ED if that's where they're going to go and manage that. Two, increase patient satisfaction in the ED. I'll talk about that later. But just to say, when you're a case manager, social worker in the ED, and you're having good communication with that patient and family, we know that it will improve their satisfaction because patients get lost in the ED all the time. And by that, I mean they're kind of forgotten. The staff in the ED is focused on emergencies. So patients waiting to go to a bed who are stable are not going to be the greatest of priorities for the ED staff. And number one, and the reason we're all here this morning, is managing the two-midnight rule. Okay. So I'm sure most of you at this point are familiar with the two-midnight rule. When it first came around, sure, there was a lot of confusion about it. I think folks really had difficulty figuring out how to do this. And as I do my consulting, I have to tell you, people are still struggling with this. You may be working in a hospital that's also struggling with this. And the difference, in my mind, with the two-midnight rule, perhaps different from some of the other Medicare rules and regulations, is that the majority of your ability to be compliant with this particular rule really requires that your physicians are compliant and that your physicians are managing their documentation appropriately because the onus of responsibility with this one really is in the majority on the side of the physician. So they say that the ordering practitioner physician must reasonably expect a patient's treatment or procedure to require a stay in the hospital lasting at least two midnights. So you may recall part of the reason why they put this rule in place was they were seeing a lot of short stays. And by short stays, they mean one- or two-day stays, 24 to 48 hours. And they were seeing those short stay patients as not really needing to be inpatient but could be managed in a different way. So this really was an attempt to reduce the number of short stays. So the two-midnight rule requires that the physician think prospectively about how long they think that patient will require care. And in order to be admitted under the two-midnight rule, the physician has to reasonably believe that that patient will be staying at least two midnights. And then that order to admit must clearly state that expectation. So I just put a couple of examples here. Admit to inpatient, expected length of stay is three days. Or admit to inpatient, length of stay will be greater than two midnights. So the physician isn't required to say exactly, like, I have three days here. They're not required to say that exactly, it's going to be three days, unless they're absolutely pretty sure about that. They can just say they believe it'll be greater than two midnights, and that's acceptable. But they have to say something about that. So if you think about utilization management in the middle here, and then you look at all the potential routes of entry, and you bigger your hospital, if you're a medical center, if you're a tertiary facility, you've got lots of different ways in which your patients are going to enter the hospital. Now, I put the ED up at 12 noon there because, and I'm giving a generalization here, 50% of admissions typically come in through the emergency department. And, you know, you may have a greater amount in your hospital. Some hospitals may have a lower amount. That's just an average. But it's the yeoman's share. So where do the other 50% or so come from? Well, they come from all these other routes of entry. So patients get bumped over into an admission from lots of different areas. Now, if you look over, I guess that's, what, 4 o'clock, transfer center. One of the things that I've noticed consistently is a lack of utilization management in your transfer centers. So when you've got transfers coming in, well, if nobody is gatekeeping them, you have the potential for a problem, just like you would if you weren't gatekeeping the emergency department. So I do recommend that you consider having some kind of attention paid to that area. You could actually have a case manager who's doing utilization do that for every other route of entry other than the ED, and that way you would cover everything. But these other areas really do need to be covered. You also need to have that, if you see on my left side here, inpatient order written. Otherwise, it's conceivable that Medicare will consider these an outpatient. And that's a Medicare thing, strictly. CMS, this is a quote from CMS, which I thought was kind of interesting. Compliant and correct physician documentation cannot be overstated. So like I said, oh, documentation is really the linchpin to this whole rule. The importance of physician documentation in the context of inpatient hospital claims cannot be overstated. Compliance with the final rule, that's the two-midnight rule, may involve the adoption of new forms, mission order forms, certification forms, and must involve thorough documentation of the need for inpatient hospital services, the physician's expectations regarding length of stay, and the rationale for the physician's opinion. So those three things at the end there are really the things that they're going to look for in terms of your physician documentation. The need for the inpatient service, the physician's expectations regarding length of stay, we were just looking at that, and the rationale for the physician's opinion. So the physician has to explain why he or she thinks the patient needs an inpatient stay and why they are looking at a particular length of stay. And they really hadn't had to do that before this. I mean, physicians really didn't have to think about how long the patient might or might not need to stay in the hospital. So this really was a big change. So this documentation is defined quite well. But the other piece of this is that reimbursement is contingent on this documentation, so if this documentation is lacking, then it is conceivable that the hospital may not get paid for the stay, so again, really crucial. Physician must document expectation to be greater or lesser than two midnights with that order. The physician must document the reason for the hospital services. Now every time a physician writes an admission order, they should be and they probably are documenting the medical necessity for that stay and what the reasonable and necessary care should be. So that piece to me is more than just a two midnight rule, it's really how physicians should document an admission. If expected stay is less, was it less than two midnights, but now the patient will continue to stay with an inpatient order hopefully written and the reason for extended hospital services. So the physician must explain if the patient's stay is going to exceed or is going to be greater than two midnights, although he originally didn't think so, they have to explain that as well in their documentation. They have to authenticate the order and inpatient only procedures would be the exception and we're going to talk about those. So the two midnight benchmark kind of drives this whole thing and there's a couple of points to consider. The ordering physician can consider time the patient spent receiving outpatient services and those might be observation services or treatment in the ED or even an outpatient procedure when calculating whether the two midnight benchmark will be met and therefore an inpatient admission medically necessary and appropriate. So what they're basically saying there is the physician can, you know, should take a look at any other services that that patient had received before they think about that two midnight benchmark. And while this outpatient time is considered for admission, it does not turn into inpatient time once the admission is written. So that's important to understand too. That inpatient stay starts ticking at the point in which the order is written. And like most rules, there are some exceptions to the two midnight rule. Unforeseen circumstances is what they like to call them. And what they mean by this is, well, the physician initially believed that the stay would be two midnights or longer. There are those situations in which the stay might wind up being shorter than that. So these exceptions would include death, transfer, transfers out, departure against medical advice, AMAs, unforeseen recovery so the patient got better faster than expected, or election of hospice care. And what they say, and CMS always uses this kind of language, they may be considered appropriate for hospital inpatient payment. So they're not saying automatically, but that they may be if they take a look at those. Physician expectations and any unforeseen interruptions in care must be documented in the medical record. So what I often recommend is if you can have a dropdown for your physicians in your EMR with these options, these choices, or unforeseen circumstances in which the patient recovered more quickly so the physician's documentation can include what is necessary to be compliant. And they don't have to think about it too much, but they can just hit the dropdown. After the initial two midnight rule came out, there was a lot of pushback by physicians and physician groups, mainly because they felt that their clinical judgment was being taken out and it was all based on timeframes and, you know, they were kind of taken out of the logical progression thought process. So after that, I think it was like two years later, CMS came out with acceptable one-day stays. So they said it would depend on the judgment of the physician whether or not an inpatient one-day stay might be acceptable. And then the physician, again, has to include the appropriate documentation to justify that stay. They also expect these to be rare, so this is not like, okay, well, now we'll just put everybody in and figure it out later. They don't expect you to have a lot of these. And if they start to see a lot, which is something that's true for pretty much everything, if they see a lot of these one-day stay admissions, they may do a review. And you don't want that, trust me. So the crux of the decision is the choice to keep the patient at the hospital in order to receive services or reduce risk versus to discharge the patient home because they may safely be treated through intermittent outpatient visits or some other care. Yes, that's exactly right. CMS sort of, you know, said what I think everybody was thinking initially, that some patients can and will recover more quickly than anticipated. So they agreed that, yeah, you know, maybe the physician prospectively truly believed that the patient was going to stay for two nights, but they recovered more quickly. Such unexpected improvement may be provided and billed as inpatient care, as the regulation is framed upon a reasonable and supportable expectation, not the actual length of care in defining when hospital care is appropriate for inpatient payment. Okay. So in other words, they're saying, well, in the physician's best guess, excuse me, in the physician's best guess, he or she really believed that patient was going to stay two midnights. A beneficiary who experiences an unexpected recovery during a medically necessary stay should not be converted to an outpatient but should remain an inpatient if the two midnight expectation was reasonable at the time the inpatient order was written, but unexpectedly the stay did not fully transpire. So that's another interesting one that you can actually bill as long as you've got all your appropriate physician documentation. Physician certification of that medical necessity is also required to establish the appropriateness of inpatient services. So it would include authentication of the practitioner's order, the reason for the inpatient services, the estimated time the patient requires in the hospital, and plans for post-hospital care. So the first three are traditionally part of this, but later plans for post-hospital care were added. So you would want to also see in your physician's documentation the initial discharge plan. And that we often don't see as well. So that again requires physician education so that they understand all the components that they have to include. Any time you can put this as a drop-down menu in your EMR, the better it will be in terms of compliance with a lot of these documentation expectations for your physicians. Authentication of the order means that the physician certifies that the inpatient services were ordered in accordance with the Medicare regulations. This would include certification that the hospital inpatient services are reasonable and necessary and that they are appropriately provided as inpatient services in accordance with the two midnight benchmark. So when the physician writes that the services are reasonable and necessary and fall into this two midnight benchmark and so forth, that is an authentication. So there's basically two reasons for inpatient services. And this also would apply if you're doing utilization management at any of your routes of entry. But this is something else you do want to think about. Hospitalization of the patient for inpatient medical treatment or medically required inpatient diagnostic study. That would be one reason. Or special or unusual services for cost outlier cases under IPPS. Now that's very unique and very specific and not something we typically get into in case management. And of course, hard to be compliant with the two midnight rule if we're also not following our rules and regs for observation. I happen to be a fan of observation, although I know that sometimes it can cause some confusion, particularly for our physicians, although I think that has certainly gotten a lot better. And observation, in my mind, really gives our physicians an extra 48 hours to make a decision as to whether that patient needs to be admitted to the hospital or can be treated at another setting. So by definition, from the Internet Only Manual, if you ever want to look anything up regarding Medicare, you can go to the IOM or the Internet Only Manual, and you can find pretty much anything there. Inpatient care is a well-defined set of specific clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. A lot of times what we used to see in these short stays, which now have become observation patients, are rule-outs. You'll see a lot of symptoms, headache. I mean, that's a silly one, but abdominal pain, dizziness, anything like that that you really don't know what's going on with that patient, so you want to do some treatment or assessing of that patient. So to me, it's an opportunity to really figure out what's going on with this patient before you move to an admission. So if it's used properly, it can be really helpful. Now, oh, I'm very upset with myself right now, Lindsay. I have the wrong slide deck here. Okay. I'm going to give Lindsay a slide that, yeah, I redid this slide, and I must have pulled up the wrong deck because there's been some big changes with the Medicare inpatient-only list. Oh, darn. This is right hot off the presses. Okay. We can make sure that everybody has the updated copy. Yeah, thank you. Oh, yeah, thank you, because we need to be aware of this. Okay. So I'm going to just tell you what these are, folks, and then we'll get this to you. So, of course, just generally speaking, the inpatient-only list includes the list of procedures that can only be billed as an inpatient. So anything that's not on the list would have to be outpatient. Inpatient-only surgeries do not require two midnights in the hospital. So, again, if you've got a surgical patient, they don't have to stay two midnights if they don't need to. No time specifications for inpatient-only, as we just said. Patient is not required to stay in the hospital after the procedure, but if the procedure is not billed as inpatient, there is no reimbursement. Any procedure not on the inpatient-only list can be performed as inpatient, observation, or outpatient. Now, I know that was an issue that had come up when NEES, I think it was NEES, moved off the inpatient-only list. It's really up to the discretion of the physician whether they want to go inpatient, outpatient, or observation service. As part of the final Outpatient Prospective Payment System Rule 2024, CMS will be phasing out its policy of paying for some procedures only if they're done in inpatient settings. So, this is really new, and it's happening now in 2024. And right now, approximately 300 mostly musculoskeletal-related services were cut, followed by the rest of the 1,700 inpatient-only list by 2024. So, what I'm reading online is that they have 300 on the list now, and then they're expecting the rest to come off the inpatient-only list by the end of this year. I haven't seen a delay on this, although it could possibly happen. Right now, this is the way it's going. So, CMS will continue to pay for those treatments in either an inpatient or outpatient setting, again, as determined by the physician. So, in summary, what we're saying here is that right now, they've taken 300 musculoskeletal surgeries off the inpatient-only list, and they're expecting to essentially eliminate the inpatient-only list by the end of 2024. So, that's the summary there of what that says, but we'll get that to you. I wonder what else I'm missing, Lindsay. Oh, dear. Okay. All right. The two-midnight rule, your role. So, when you've got a dedicated observation unit, goodness sakes, it makes life so much easier, doesn't it? I'm not a big fan of scatterbed, as we call it, where you've got your observation patients kind of all over the place, because it's really hard for the nursing staff to remember it's an outpatient, for case management to expedite the treatment or work up for those patients. So, we do like to see dedicated areas for the observation patients. Regardless of where they are, however, you want to reassess them after one midnight. So, the second day, or I should say after the first 24 hours, is really when you want to get at it, because, yes, the two-midnight rule is 48-hour benchmark. However, the reimbursement for observation is averaged out for a 24-hour period. So, at the end of that 24-hour period, you do want to really take a hard look at your observation patients. You want to do that as early in the day as you can. If the patient is going to be transitioned to an inpatient, documentation would be required with the reason for the extended hospital services. So, again, that's your physician. And if observation service continues, and that should be rare, again, you know, you don't want to have these prolonged, protracted lengths of stay of patients in observation. Coordinate your discharge as soon as possible. So that 24-hour period should really be the driver for when you try to get a decision made about what's going to happen with that patient. So let's talk more about what your requirements, your job is, really, as it relates to managing these observation patients. So again, each morning, work with your attending physician or your hospitalist or whomever is responsible for that patient. If you've got hospitalist service patients, co-mingles, again, focus on them, too. Initiate discharge planning if the patient is no longer meeting medical necessity for observation. Discuss their status on rounds. And that you should do every day because it is very easy, particularly with the scattered bed approach, it's very easy for practitioners to, maybe not the physicians as much, but for others, to forget that this is an outpatient, an observation patient who requires expedition of their care. Consider the possibility of transitioning that observation patient to inpatient. You want to take a hard look. Are they meeting medical necessity? Can we get physician documentation that will support that? If the physician advisor states the patient meets observation only, review the medical record, discuss the possibility of additional documentation with the physician. So there you go as far as, you know, pulling in your physician advisor, looking for additional documentation, which we have talked about many times. So let's look at how we might pull this into our daily routine. And it really should, after time, be just kind of what you do every day without worrying about it too much. So I like to call this the perfect world. The patient is admitted as an inpatient with an appropriate order. The physician documents that appropriate medical necessity. So they're following all those rules that we talked about. The case manager reviews the order and the documentation using medical necessity criteria on the day of admission. If it's a one-day stay, the physician documents the reason for the early discharge, and again, we looked at those exceptions. The patient is discharged and the appropriate bill is sent. Beautiful, beautiful, beautiful. Don't you love it, things to work perfectly each and every time. Now I've mentioned Medline Matters before. I'm going to mention it again because the self-denial process is very important. Now it's been around for 10 years now, but it is what CMS expects us to do for our Medicare patients. And remember, we've talked about the fact that when we send clinical information to a commercial payer, they're making a determination as to medical necessity. However, for your Medicare, your traditional Medicare population, CMS has delegated that responsibility to us, the hospital. So when we do a clinical review on a traditional Medicare patient, we are making a determination as to medical necessity. And along with that comes self-denial. So when we identify a patient who does not meet medical necessity, it is expected that we are going to follow a process. And they do allow us to rebill using Condition Code 44 or provider liable billing. So they do give us an opportunity to correct our mistake. So Condition Code 44 allows us to bill Medicare Part B if the patient has an inpatient order but does not meet medical necessity and has not been discharged. So that's the linchpin for Condition Code 44 is that the patient has not been discharged. So you may, you know, do an initial review of the patient and see that they're not meeting patient medical necessity but they're still in the hospital. In this case, you're going to get less than the inpatient stay in terms of reimbursement but more than provider liable. The entire stay is going to now be billed as outpatient. The patient must be notified in this case of observation service. And they may be billed. And I say may because a lot of hospitals don't really do it. But they may be billed for their responsibility in that bill. And that can be certain services that aren't related to the reason they're being observed. Observation hours begin at the time Code 44 is implemented. And again, you've got to have a member of the UR committee participating in this process. That's usually the physician advisor. But it doesn't have to be. So the less than perfect world would involve using Condition Code 44 then. So the patient is admitted as an inpatient. The physician documents inappropriate or incomplete medical necessity. So in this case, we don't have all the physician documentation that we require to be in compliance. The case manager or the attending physician identify inappropriate admission inpatient order. The attending physician and a member of the UM committee agree the patient's status should not be inpatient. So now we've had a little powwow between the attending physician and maybe the physician advisor or some other member of the UM committee. And then the physician and the UM committee member document that observation would be appropriate. And then appropriate billing would be Condition Code 44. And as I said, that's going to be less than, because it's really Part B billing only for Condition Code 44, less than an inpatient stay. And then we have provide a liable billing. This is what you're going to use if the patient has already been discharged. So you go through that same process. The patient is reviewed in the morning. They were admitted maybe, let's say, overnight or something. And you're going to review them. And they've already left the hospital. You're doing a retrospective review. And they didn't meet medical necessity. You have to withdraw a claim for an inpatient stay if it's already been submitted. Probably hasn't been, but you never know. And then you're going to bill provide a liable, which is less payment, less things covered with provide a liable than even with the Condition Code 44. And as I said, the patient might be liable for some copayments, cost of self-administered drugs. So drugs or medications they may take that aren't related to the reason for the observation. A lot of hospitals don't do that, but conceivably, you could do that. And again, in order to go through this, you will need your physician advisor. And just to say, the patient's already been discharged. The billing isn't going to affect that patient's stay. And the patient does not have to be notified in this example. If you're going all the way back to provide a liable, the patient does not have to be notified because they're not being put in observation. So it looks like this for your provide a liable. Patient admitted as an inpatient. Physician documentation not in compliance with the two-midnight rule. One or two-day stay occurs without concurrent case manager review. So maybe it was over the weekend. Maybe you were short-staffed. Patient is discharged. The account placed on hold, the case manager does a retro-review after discharge and utilizes that physician advisor to see that the two-minute rule documentation requirements were not followed. And then we would follow our self-denial process. So in this case, again, patient's been discharged. It's going to be provide a liable. So just to add, what are ancillary services, you might be wondering? Hospital services that can be paid by Part B outpatient billing are considered to be your ancillary services. So those are the kinds of things that would be covered that wouldn't be otherwise covered unless you follow this process. So just let me give you some payable ancillary services examples. Diagnostic x-ray tests, diagnostic laboratory tests, x-rays, surgical dressing tests, prosthetic devices, these are all ancillary services, leg, arm, back, and neck braces, trusses and artificial legs, arms, and eyes, outpatient PT, speech therapy, and OT, and ambulance services to and from the hospital all fall under these ancillary services, and there's lots of others. Now CMS tells us, you know, we don't want you to use Condition Code 44 or provide a liable as a standard practice, and oh, my God, in the beginning of this whole thing, so many hospitals were like, let's just admit everything, and then, you know, we'll back it out later, let's just take our chances and all of that. There's so many compliance issues in that one statement, right? You know, there's self-denial, there's just so many things. So CMS said, the use of Condition Code 44 or provide a liable Part B billing pursuant to hospital self-audit is not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians and hospital staff about each hospital's existing policies and admission protocols. So they're saying, just because you're not staffed correctly in your case management department doesn't mean that it's okay just to go ahead and admit everybody. So they were pretty clear on this point that a lot of hospitals, you know, just figured they could get away with that. Okay, access point case management. So I call it access point case management because, as we saw that circle earlier, what we saw was all the different routes of entry that patients may take to get into the hospital. And so access point case management is kind of the blanket term for the processes we use for any point of entry. So we had the 2014 IPPS final rules and then, believe it or not, when things moved over to outpatient prospective payment system in 2015. So that was when observation moved over the OPPS final rules. So both times they said we have to be compliant with the two midnight rule, we have to have an order to admit, and we have to provide for alternative care when needed and appropriate. So when the patient doesn't meet medical necessity, the other thing you're expected to do, and again, if you don't have case management in the ED, you're not going to be providing for alternative care. So this is why we look to see our best practice, ED case management models, or any other route of entry. So as I said, we essentially should think about having ED case management because there's a big percentage of patients coming in that way, but then also having case manager following those other routes of entry. So the goals for access point case management would include managing and controlling the types of patients approved for admission, again, regardless of route of entry, provide for alternative care or level of care when needed and appropriate, regardless of route of entry, and when you do all of that, what you're ultimately doing is increasing the likelihood that the hospital will get paid. So I've called it the admitting department case manager, it could be the transfer center case manager, again, depending on how you want to set it up. Back in the day, I always had, we didn't have a transfer center in one of my hospitals where I was a director, but we did have a case manager sitting in the admitting office. She physically sat there and worked with the admitting staff. So she was looking at planned admissions, urgent and direct admissions, and she would also look at transfers, transfers coming in, obviously. So she had basically everything other than the emergencies. She would provide a screening of potential admissions and or transfers using her clinical indicators, if it was Interqual or Millman, making sure the patient met the level of care that the physician was seeking at that point in time. When the patient's needs didn't match up with the admission criteria, she would contact the physician, discuss potential alternatives, care alternatives, to that admission with that physician. And today, we have so many other options, ambulatory surgery being such a big thing now that, you know, it's easier, I think, to have alternative opportunities discussed with the physician. You know, and if the physician really wants to have that patient admitted, then they're really going to have to have robust documentation that's going to support that. Of course, these are some of your alternatives. So when you're looking at having, let's say, a nurse as your admitting or transfer center case manager, they also have to not only be versed in utilization management, but they also need to have some understanding of discharge planning as well, because if they have to set up some of these other levels of care, obviously, they need to know how to do that. Now, you never can deny an admission without providing the physician with alternative setting options. And what I always suggest is when you go to talk to the physician, go with the alternate plan in mind already. That really does smooth that out a little bit. And you can talk about it more appropriately, meeting the patient's needs and more likely for the hospital and the physician, frankly, to be reimbursed. Because it's possible the physician can get a denial too. They do get denials. They don't get many, but they do get some. And of course, screening transfers is part of this role as well. So ensuring that the transfer is appropriate and meets all the Medicare guidelines for appropriate transfer is another role that this physician can provide. And then after the admission has been approved, the case manager can communicate that to the admitting office. If you have a bed czar, as I like to call them, if you have somebody who's managing where the patients go, you know, controlling the bed movement of the patients, some of you may have software that helps with this. If you have somebody who's doing that, then they may also need to be notified. And then the case manager may be the one to obtain the pre-author approval from the insurance company, or that might be delegated to a clerical support person. If the third-party payer is asking for additional clinical information, then this, again, is a perfect role for that case manager, because they're providing that link between the clinicians, the physicians, the admitting department, and that insurance company. And there may not be anybody else to do that. Now, somebody in the doctor's office might be able to do that, and that's possible too. Now, the other thing that's become extremely popular are the same-day admissions, so patients coming in same day, usually for surgery. What we would do with that is make sure that that patient prior to the day of admission has a pre-auth, and the patient is being admitted at the right level of care that meets medical necessity. And now with all the changes with the inpatient-only list and all of this other stuff, this is an important thing. Yes, you know, the patient's been pre-auth, but is this meeting medical necessity? Another thing this role can do, which I think is kind of neat, is if you have the physical ability to do this, and by that I mean, is the patient going to be anywhere near where the case manager is during the pre-admission testing process? So this is an opportunity for the admitting case manager to intake some groups of patients during the pre-admission testing process, and you can see this lots of times with your orthopedic surgery patients, you know, going through that pre-auth process. They can have an initial conversation with them about discharge planning, what to expect after discharge, what their needs were after discharge, and get the ball rolling as far as that is concerned. They also may pick up on some issues that might affect that patient's in-hospital stay or that might affect the destination that we're selecting after discharge. You know, maybe the initial thought is to send the patient home, but it turns out that that, you know, patient really isn't going to be able to manage at home for one reason or another. So, of course, the family as well as the patient should be included in discussing discharge planning options, discuss with the attending physician when post-discharge needs are clearly identified. So, in other words, you've come up with a plan and you want to discuss that with the attending physician. If you have some issues, yeah, you want to document those in the EMR and you might want to also have a verbal handoff to the inpatient social worker or case manager depending on how significant your findings might be and how much you think they're going to interfere with that patient's stay or discharge plan. All the information that you've communicated, again, should be communicated in one way or another and documented. If you have the opportunity in your EMR to write a pre-admit note, usually you can, or if you have case management software, you can certainly document it there as well. That way, you've got a good transition process in place, but again, I do recommend a verbal handoff once you know where the patient is going. Okay. So, that role, again, that's your role for your admissions or anything other than emergencies. And I do recommend if you don't have such a role, it leaves you really vulnerable from all those other routes of entry. And that brings us to our emergency department case management. So, even though we didn't think that a lot of patients are still going to emergency rooms, particularly with all the urgent care centers around, we still are seeing increasing ED visits, and this is attributed to the use of EDs for non-urgent complaints. And what's interesting always if you talk to patients, they really have this perception that they're going to get treated much more quickly if they go to the ED than if they go to an urgent care center. And as we all know, if they fall low on the triage scale, they're probably going to spend a lot more time in the ED than they would going to an urgent care center, but it's hard to break people's perceptions. And then, of course, we want to keep patients out of the hospital to the extent possible that we can do that. So, some of this has to do with the non-emergent patient sometimes being your indigent patient, sometimes being your patient who doesn't have a primary care provider, can't get to that primary care provider in a timely manner, and really just uses the emergency department as their primary care provider. I have a relative who does that. Rather than thinking about getting an appointment, or they can't get a timely appointment, they go right to the emergency department. Really not for routine treatments, not the place you want to go. So, when you think about what I like to call the new ED, it's an access point, but it's also an exit point. So, for our case managers in the ED, you want to think about your discharge planning just like our other admitting role. You really do want to think about your exit points. And if you don't think about it that way, you really do need ED case management. Now, lots of times the ED physicians are quick to admit. But, of course, again, with the two midnight rule, we need to work hand in glove with them. Is this a discharge? Is this an observation patient? Or is this truly an admission? And if it's going to be a discharge, do I need to set up any services for that patient in the community? Is this patient going to need home care, for example? That's sometimes an intervention that you can provide that's going to prevent an unnecessary admission or readmission. So, this gatekeeper role in the ED is really important. You want to screen all your ED patients for appropriateness of admission, offer those alternative care settings or levels of care, initiate contact with the admitting physician, ED attending, and primary care physician. So, you want to, you know, however your hospital, you know, whoever's appointed, if you will, to do the admission. Sometimes it's the ED physician makes the recommendation and then the inpatient person does the admission, like the hospitalist, for example. So, depending on how you have that all set up. You just want to make sure you're contacting all the appropriate people. And you probably want to provide clinical and payer information to that physician or physicians. Now, you also want to think about ED triage for your patients. Because you may have, you know, 30, 40, 50, 60 patients or more visiting the ED every day and you're not going to be able to assess or intervene on all those patients. And you don't need to necessarily, but you do want to have some kind of a way in which to prioritize those patients. So, I like to call it ED case management triage or you might want to call it something else, but I kind of like that. And you can come up with your own criteria depending on what kind of vulnerabilities you're experiencing in your own hospital. But the big one typically is a potential 30-day readmission. So, you want to take a look at that and if this patient has been discharged within the last 30 days. One of the clinical information systems in the ED will flag these patients for you or highlight the patient so that you know, uh-oh, this is a potential 30-day readmission. And what you really want to do is have case management intervene on any potential admission in the ED and have an opportunity, particularly with the readmissions, to assess whether or not that admission is appropriate or necessary. Potential observation patients based on the two midnight rule should be part of the ED case management triage. Patients who can be discharged from the ED but will require follow-up services such as home care in the community, as I mentioned. I even had a system where I had a rapid referral to home care from the ED because that can be a delay issue if you don't have some kind of a process set up. Inappropriate admissions such as social admissions and frequent visitors, frequent flyers, friendly faces, whatever you happen to call these folks. But these are people who are in and out of the ED pretty regularly and are kind of known to people. And another thing you can do with those is if it's somebody who's drug-seeking, just as an example, you can have a plan developed so that the whole team knows about this patient and can respond appropriately when they come back. So in addition to gatekeeping, they should also be coordinating and facilitating care. So on the treat and release patients, on admitted patients, and on observation patients. Now, that's not to say they're going to coordinate and facilitate care for all of these patients. That would be crazy. So particularly on your treat and release, those are probably your lowest priority because we know they're leaving. On admitted patients, probably your highest priority, or one might argue observation might be. I would say on admitted and observation patients, if you can, just make sure things are moving along and delays aren't happening. So these are some of the examples of the kind of things that you might want to intervene on. You know, I'm hesitating so much here because I had so many other slides in here, Lindsay, that are not here, and I'm disappointed in myself. But I'm going to give you this new slide deck afterwards, Lindsay, and I think we should read. Yeah, there's a couple of slides that I had added that aren't here. Okay. I mean, if you have the other one up, Dr. Sista, and you want to stop your share and re-share the other ones, we can do that. Or if you just want to keep moving forward, whichever you think is best. Yeah, that's a good point. Because I had some stuff on readmissions and things. Yeah, let me see. Is that okay if I? Sure. Yeah, absolutely. That way everybody can see it. I hope I can. Yep. You got it. You got it. Stop. And then you can just re-share the updated ones, and that'll be great. All right. I hope I can find it now. Let me look. And then while Dr. Sista is doing that, I did post a comment for you all in the chat, but we will have some time at the end of the presentation. And a wonderful benefit about attending these live sessions is that you do get this live opportunity to ask questions of Dr. Sista. And I know that she has a wealth of knowledge that she is more than willing to share with you all. So please take the time to type in any questions that you may be thinking of into that Q&A option so we can make sure that we have time to address those at the conclusion of the presentation as well. And then as she mentioned, we'll make sure that you all get that email tomorrow morning that will include a link to the slides that she is presenting today as well. Thank you. Okay. Of course, I'm not going to find it, you know, because everybody's waiting. Oh, do you have it, Lindsay? Because I sent it to you. I'm not seeing it. I don't think I put it on my OneDrive. Oh, Lordy. I'm not sure if I have the... I'm sure you sent me the updated ones. I hope so. Let me look on my... Everybody can have a quick bathroom break, maybe. There you go. I'm going to take just a couple of minutes of a break here. Biology break, right? That's right. There you go. I'm going to forward you back to what you sent to me, and then you can see if those are the... Oh, good. Good, good, good. Thanks. The ones that you're looking for. This is hard when I can't go to my office. I don't know. I should tell everybody I have a... I had ankle surgery, and I can't go to my office, so I apologize. She's powering through and still doing this series for us, even though she had a major surgery not too long ago. Yeah. I'm sorry about this. If I were in my office, that wouldn't be an issue. I think it'll be good for everybody to see the ones that you're speaking from, and then that way, once they get the copy of them, then if they have any questions, they can always follow back up with us. Yeah, because I do update them every time I do them. Of course. Okay, so this is... I know. Okay, I got it. Since I've been laid up with my ankle, I've been watching. I bet. All right, let's see. And if what I just sent you is not the updated copy that you're looking for, then again, we can just make sure that everybody gets a copy of that tomorrow morning. All right, okay. Am I boiling it right now? That should have been slideshow. So then that means that everybody has the correct slides in, so that's good. Ah, oh, that's true. I didn't even think of that. Yep. Okay. I just want to see if there's a couple that I want to share. Real fast, and then we'll get back to where we were. Yeah, sure. Let me just share the slides. Okay. So I had, I was reading, this slide was one of the ones. So you'll see in the slide deck that I didn't show you today what ancillary services are. So I had read this to you, but just so you can see, because people get asked that a lot, well how can we get paid less because of these ancillary Part B services? And these are the payable services that I read to you. And this is, again, why, you know, you don't want to do Code 44 unless you absolutely have to because you're not going to get paid for all the inpatient services but just these ancillary services. Okay. There. I feel better about that. All right. Let's see. What else? I'm just going to scroll through here. I know nurses and social workers are very kind people and everybody will understand. Absolutely. Okay, so I also just put a definition of what treat-and-release patients were. So these are short-term treatments generally requiring a minimal post-discharge follow-up. So when you treat and release this, you want to probably have some kind of a very easy process for your staff nurse and the ED to let you know this short-term, you know, treat-and-release patient might need some post-discharge follow-up. Really should be very minimal or non-existent. And it's possible they've already been to primary care. Again, it's only about 4% of these. But they might have already been to primary care or an urgent care center before they get to the ED. So you do want to, you know, ask that question as well. All right. I had also changed up my prioritizing patients list a little bit from what we looked at a few minutes ago. So we talked about prior admission in the last 30 days, a recent seven-day treat-and-release episode. So I had updated this because we're getting more and more information about how we should prioritize our patients based on people's experiences. So frequent and recurring visits and admissions, of course. And again, a lot of this data you can have pop up on your electronic record in the emergency department. If they don't meet admission criteria, now, you're not going to know that unless you're getting to a large percentage of them. If they require alternate care, if they've come to the ED from a skilled nursing facility. Now, that can be a big one depending on your hospital. But a lot of times, and it's gotten better, I have to say, but a lot of times your SNFs are sending patients to the ED for something, you know, pretty minimal. And then they can go back to the SNF. So you don't, you really kind of want to interject yourself on those so they don't get admitted. Throughput for your OBS patients, any social determinants of health issues that may pop up in the ED. And you may have some diagnoses that are specific issues for you and your hospital. Every hospital is going to have different issues. But if you have issues on a particular diagnosis or there's been a big sort of full court press on a particular diagnosis, then you want to, you know, interject yourself on those as well. So a note on inappropriate admissions. They impact quality and patient flow. They can impact length of stay. You've got a patient who doesn't need an inpatient bed, taking up an inpatient bed, keeping an appropriately sick patient from getting that bed. Impacts patient safety, could result in a denial. Affects your bundle payment system, obviously, you know, adding to cost, as well as readmissions and the efficiency measure. So the last three there go beyond, you know, just that single patient and that single bed because it becomes a statistical issue for you. So I also included here a readmission risk assessment. I believe that when you identify that readmitted patient, you should consider doing an admission assessment and incorporating into that admission assessment would be a readmission risk assessment. So this is a patient who's getting readmitted, perhaps maybe appropriately readmitted. So in my mind, it doesn't have to be that complicated. You really want to ask some pretty fundamental questions. What failed in the community that brought this patient back to the hospital? So was it medication management? Did they take too many pills or not enough pills? Were they having pain that they couldn't control? Did they have an issue with their diet? Maybe their heart failure is exacerbating after having Chinese food the night before. They missed their MD appointment or appointments, and they're not managing well. They couldn't get to the physician's office, so they went to the ED for some other reason. So these are, you know, I've done a couple of studies on readmissions. I think I've mentioned that before. And we've come up with sort of some pretty basic, classic readmission issues. So I just wanted to show you these. You know, you don't have to make this into a big, complex thing, but if you ask these questions and you get an answer that needs to be addressed, well, then that has to follow through in terms of your discharge planning. If this patient is, you know, having transportation issues or managing their medication issues, you have to address that in your next discharge plan. So it kind of informs what you're going to do on this particular readmission. So for the case manager, RN, in the emergency department, you're going to do this intake assessment of the admitted patients, as we just talked about. You should do an initial review of your admitted patients. Again, you're not doing reviews other than on admitted patients. If the patient's there long enough, and I certainly hope they aren't, you might have to do a continued stay review. You're going to coordinate and facilitate a plan of care for an admitted patient. If they're there long enough for you to do that, you can begin pulling together that plan of care that we've talked about. Screening or assessing patients for psychosocial needs in conjunction with the plan of care. We're expected now, again, to look at those social determinants of health. You can even build that into your admission assessment tool so that you are addressing those issues. And with some of the social determinant issues, whether it's medications or food insecurity or any of those particular issues, there's more and more literature coming out about how to address some of those things in the ED. And I've been reading about pharmacists getting more involved in the ED, giving vouchers to patients for food. So there's lots of creative things you can do with your ED case managers. And then, of course, the discharge planning, which could be equipment, you know, DME equipment, home care, infusion. It could be a number of things. But again, preventing an unnecessary admission. Other things would include initiating that inpatient discharge plan. So the patient's being admitted. You may even want to make a home care referral right then and there, you know, for an inpatient. Believe it or not, that can really expedite things. If you have clinical guidelines in your ED, you can work on those with the ED staff because we have a part to play, especially now with the two midnight rule in terms of a lot of this stuff. You should, we've talked about avoidable delays, and you certainly should be part of identifying those, or quality of care issues, throughput issues. Your clinical resource for staff. Usually our case managers have more experience than the average staff nurse, so you can certainly be a clinical resource. You also can help facilitate the patient's progress through the ED to disposition. And disposition would be inpatient or discharge. You can also see or facilitate transfers from institution to institution. So if the patient is in the ED going to another institution, you can help with that too. For our social workers, now I do recommend, and I get asked this question sometimes, should we have RN case managers in the ED? Should we have social work case managers in the ED? And the answer is yes, you should have both disciplines in the ED. So we just saw some of the things that the RN should focus on, but then we have the things that our social workers should focus on. And of course, going back to those social determinants, I should say, social workers are perfectly poised to deal with those kinds of issues. And I just put some more examples of here of where the social worker really performs a different discrete set of work from the RN case manager. So patients or families having difficulty understanding, accepting, or following through on the medical plan of care and continuing care options. So again, sort of that counseling role. Issues regarding issues impacting on accessing continuum of care, such as immigration issues, primary caregivers or disabled persons, you know, really important there. Advocacy and counseling around entitlements or food stamps, housing, again, all social determinants stuff. Suspicion or evidence of domestic violence, elder abuse or neglect, child abuse or neglect, sexual assault. More social work stuff. Ethical or legal concerns, such as patient, family, team conflicts related to the medical plan of care, guardianships, end of life issues around advanced directors. So I've heard people say, well, what does the social worker do in the ED? There's so much need for social workers in emergency departments. Materials needed for marital, individual, or family treatment, assistance needed in locating families. Oh, we used to do this a lot when I worked in New York City. Families of identified seriously, unidentified, excuse me, seriously ill patients. Oh, that used to happen quite a bit. Tracking of difficult to locate patients for follow-up medical care. So again, oh my goodness, so much. And then there will be some shared responsibilities, and I'm kind of a purist typically on what I think the RN should do versus what I think the social worker should do. However, in the emergency department, I do believe there are some things that need to be shared, can be shared, should be shared. And if you've got staggered times where the social worker is the only one there versus the RN, you must learn to share some of these things. So both disciplines can coordinate and facilitate plans of care for discharged patients, help with transportation, patient education, crisis intervention, although we much prefer our social worker colleagues on crisis intervention, it could happen. Referrals for nursing homes, adult homes, or shelters, referrals for detox or issues of non-adherence or compliance could be shared. Is it optimal? No, but it can happen. Okay, I think what's happened now is we've got a duplicate because of the other slide deck. Again, the coordinating and facilitating care, as we talked about, things that you can initiate care on. And again, this all has to do with patient flow. It has to do with how you move a patient through a very hopefully quick little piece of the continuum, but optimizing that time that you have with that patient in the ED. So getting the meds given, and the tests done, and the procedures, and maybe getting that consult, getting records from outside, and so forth. Starting the intake process, you know, and this is an opportunity, maybe the family came with the patient or they followed the patient to the ED, what's their current living situation? If they came by ambulance, how did they get picked up by the ambulance? What was the situation? Did they have informal or formal support systems? Do you have any lab or ancillary test results? And initiation of treatments, as I said. Also, do you have CDI, clinical documentation improvement staff, in your emergency department? You may or may not, or maybe they float there, but there can be some opportunity for documentation improvement right in the emergency department. And I just put some examples here, and if you note, there are also examples of the kinds of things that maybe should be more observation than inpatient. So chest pain, which is a symptom, abdominal pain, which is a symptom, rule out sepsis, pneumonia. So you can see, if you're familiar, as we've talked about the DRGs back in our first boot camp, pneumonia versus pneumonia with respiratory failure. So writing just pneumonia versus writing pneumonia with respiratory failure requiring mechanical ventilation, you know, is a big, huge difference in terms of reimbursement. So any of these rule outs, again, jeeps, should this be observation maybe? Other roles might be interfacing with community agencies. Again, if you've got a high utilizing patient or a frequent flyer, then you have that plan. I mentioned that plan earlier. Everybody on the team should know this patient, you know, you might not be on duty, the physician or the staff nurse, some of the times when that patient comes back, so they don't realize the patient's been back three other times since they last saw them. So having a plan that pops up or is available in some fashion for the entire team alerts everybody to the fact that this is a frequent flyer, referring patients to other areas and monitoring of those avoidable delays. Just some examples of your community agencies that you might want to interface with from the ED that can be really helpful. So if you need to start your discharge planning, and many times I do suggest that you do that, again, speak with the ambulance staff if that's an opportunity. If you can meet with family and friends, if they're available, start to talk about the notion of home care, if it's appropriate, not all patients in the ED and the situation that they're in are going to be in a right position to have that conversation. But if you can, you know, you can start to think about that. Interface with your inpatient case manager if you're in a situation where, again, they need to know big time what's going on and try that verbal handoff. One of the things we also do is we teach the ED case managers and social workers to check to see if the patient has a primary care physician and they're comfortable with them, they have relationship with them, because that's sometimes the patients who will be in and out of the ED because they're not accessing a primary care provider. Now how you choose to define high utilization patients is really up to your department. I'm just giving you an example here. Typically in the ED, at least once every three months. Now you may say that's too much, that's too little, and that's okay. Again creating that plan with the ED staff and the primary care physician, if they have one. They could be patients from detox, rehab programs, SNFs or group homes. Help obtain meds. If you have a wanderer, particularly if you're in an area that's more populated and patients kind of wander in, usually somebody will come looking for them. So just kind of wait the situation out. Don't enable them if they're frequent flyers with meals, showers, clothes or money and use a consistent approach. And that means the whole team has to use a consistent approach. So you also want to engage your triage nurse so they know what the criteria are for case management as well. And they may also be able to refer a patient to you right from triage. Over time, I have to tell you, over time, EMS and the police and all the staff members kind of catch on to case management's role and what kind of patients they're looking for. And with that, you'll get more referrals that way too. Inpatient case manager. Oh, I just discharged this patient. I think they're gonna go right back to the ED. That happens and you can alert them to that. Sometimes family members will come up to somebody and say, I think my mom needs the case manager or the social worker. And even community agencies may refer. So issues of noncompliance. Who focuses on those? Well, what I've done in the next couple of slides is I've split out what the registered nurse might do in terms of compliance versus what the social worker might do in terms of compliance. So for our nurses, assess the patient for knowledge deficits. Did the patient not be compliant and wind up back in the ED because of a lack of knowledge of what they should do or lack of understanding? They might've been educated, but they didn't understand or retain it. So does that require more education or do they need meds or follow-up appointments? On the social worker's side, maybe the patient's refusing to accept the services or they wanna leave against medical advice. In those examples, social worker can intervene or it's a crisis issue. And they're noncompliant because of substance abuse or family dysfunction or coping difficulties. In that case, the social worker can intervene. When it's issues of payment, underinsured or uninsured patients, the registered nurse can certainly answer questions about insurance coverage, but our social worker colleagues can help with entitlements. Maybe the Medicaid lapsed or something of that nature or get them connected up to community services. Maybe they're a veteran and they can get their meds that way. Maybe the patient's having trouble obtaining medications. The nurse can ask the physician to prescribe the least costly drug. Sometimes physicians just knee-jerk order certain things, but they're very high cost. Sometimes if you have a dispensing pharmacy in your hospital, they can give you maybe some meds to tie that patient over until they get their prescriptions filled. Another system I've used is a voucher system with a local pharmacy. You can certainly do it with your own pharmacy if you wanna do it that way. So in other words, rather than giving the patient some meds, like a handful of meds or money, which most of us don't do, you can give them a voucher and they can go to their local pharmacy where you've got this relationship and they can fill the voucher and then the hospital reimburses the pharmacy. That way, you know the patient's getting the meds with the voucher. On the social worker side, again, referral for entitlements or negotiating a payment plan maybe with a local pharmacy. I mentioned the VA hospital. Sometimes patients are veterans and they've just never pursued that. And again, the voucher system could be done by either discipline. Homeless patients. Shelter referrals with a medical component, if that's needed, can be done by the registered nurse. Social workers, you know, social history, finances, shelter requests, family friends, and frankly, any of those other social determinants. But in terms of homeless patients, to the extent that we can do something to help them get some kind of housing, albeit preliminary, perhaps. Your social work issues. We looked at some of that stuff just a few minutes ago, but again, child abuse or neglect, domestic violence, counseling, crisis intervention, legal concerns and guardianships and all these things really belong to the world of social work. Social workers are in the best position to do that. Social workers are in the best position to deal with these really intense kind of things. Case loads and coverage hours. You really want to, at the minimum, I know a lot of hospitals have gone to 24-7 ED case management. I don't necessarily believe that every hospital needs that. There is definitely a downtime, usually somewhere between midnight and 6 a.m., depending on your hospital. Some hospitals' high peak times are 11 to 11 or noon to midnight. I've seen some earlier, but you really want to look where your most volume comes into the ED and the majority of your admissions are happening, and you want to optimize those hours the best that you can. So one of the ways in which you can do that is to stagger the hours of the social worker and the nurse manager, and this way you've got maximum coverage. So by that I mean maybe social worker comes in at 8 a.m., and maybe the case manager comes in at 11 when those admissions and the walk-ins are really picking up. So social workers can deal with anything that came in overnight, and then the nurse comes in at noon, and again, you just stagger throughout the day so you've got really good full coverage. Number of staff will depend on your ED volume, your payer mix, your admission volume, and it's hard to give a number. It's also hard to tell you exactly what a caseload or how many patients that ED case manager would exactly cover because it really depends, but I've never, you know, how many you can touch in a shift, if you're a 12-hour shift, you know, it's really gonna depend on how complex that day happens to be, but you wanna cover, touch as many as you can, obviously. You also wanna measure the success of your program as you go forward. People are gonna ask, well, what is it doing? And these are many of the things that I would suggest that you consider. Admission denials, readmissions, length of stay, patient sat, and physician satisfaction. Decrease in the number of high-utilization patient visits and decrease in inpatient length of stay. So, admission denials. So you're reviewing for appropriateness of admission and promoting accurate documentation, particularly on admissions, and by that, you should start to see less admission denials. Discuss treatment and discharge plan with the physician. That will also help. And, you know, conduct physician education where you can, including community resources and other options. You know, you really do wanna engage your physicians in these conversations so that they're at the right level of care and that they're getting what they need to get if they're not gonna get admitted. And then, as we saw, we wanna have a reduction in readmission, so that's another measure. Review patients in the ED who have been discharged within 30 days or less. Consider alternatives to readmission with the physician. And watch for patterns by diagnoses, admit source, or physician. So you're gonna look at these and look for reductions in these, but you also wanna start to look at the data. You know, you may see a particular physician who readmits a lot, or, as I said before, you may have a problematic diagnosis. And with those problematic diagnoses, you see a lot of readmissions. So the data will help over time to help you understand where you're doing better and where you can continue to do better. Decrease in inpatient length of stay. Believe it or not, the earlier you intervene in the ED, the quicker the progression of care equals an earlier inpatient discharge. Make the best use of the time the patient spends in the ED, and tests that are ordered from the ED are often given priority over those ordered from an inpatient unit. So get that stuff ordered, and then try to get it done if you can. Patient satisfaction. I have to tell you, patients love it. They love that they're being kept aware of what's going on, and I'm talking mainly about inpatients. Patients admitted, I'm waiting for a bed, you know, and they're waiting, and they're waiting, they don't know what's going on, or they've been put in observation, they don't know it. So keeping the patient informed is a real big satisfier. Expediting their tests and procedures and circling back to them over and over again, they'll see this as caring. And it really is, you know, because they typically fall through the cracks. As I said earlier, your ED staff are focused on admissions. So patients that have been admitted and are waiting to go, you know, the ED staff have moved on to something else. So we can fill in that gap there. And then physician satisfaction. You should notify the patient's primary care provider that their patient is there, and then if they get admitted, re-notify them, and then gather any history from the physician on that patient if necessary. And then, of course, length of stay in the ED. Now, when I've ever set this up, and the ED physicians will say, well, while case management's reviewing this case, the level of care, you're increasing my length of stay. Well, you know, this should be a pretty quick process, and it shouldn't have a huge impact on the overall length of stay in the emergency department. But you can do other things to help with that. So you can anticipate ED discharges and get with family and friends early in the stay. Work with your community resources. Make social work referrals. You know, just do as much as you can to move things. Okay, whoop. Looks like I finally made it to the end. Whoa, that was a tough one. No problem, no worries. I'm glad that we were able to get that slide deck up, and then, of course, everyone will have that link to those slides, too, so that will be great. Yeah, thanks a lot for that. Yeah, so before we do kind of any wrapping up comments here, I'm gonna give everybody just an opportunity to type in any questions that you may have into the Q&A option found there at the bottom of your Zoom window. Or if you don't see that as an option, you can type that into the chat as well. And then, Dr. Sesta, I do see that one question came in here while we're waiting on others. It asks, will you refer to the nurse as the case manager and the social worker as a social worker? Is this based on historical trends or anything else? Well, it depends on how you wanna title it. See, to me, case management includes all the different roles. So it includes utilization, distress planning, care coordination, whereas the social worker is not doing all of those roles. But I've certainly seen lots of hospitals call the social workers social work case managers. But I've also seen lots of hospitals just call them social workers because that's what they're essentially doing. And even when a patient is followed by the social worker, they're also gonna be followed by the RN for those other roles, so the utilization and other things that the RN will be doing. So it's my preference. It doesn't have to, certainly have to be yours. But historically, I think that's the way things have been moving, yes. Perfect. Okay, and I see that one participant has her hand raised and I just reached out to her to see if she had a question. So we'll wait to see if that comes in. And while we are waiting to see if there are any additional questions, let me just give you some closing remarks here. You will receive an email tomorrow morning. And if you join us for part one, then this process should sound familiar to you. But the email will actually come from educationnoreplyatzoom.us. And so because it comes from that Zoom email, those messages do seem to get caught up in your spam or possibly your quarantine folders. So if you don't see that email in your inbox in the morning, I do encourage you to check those additional folders. And then if it's still not there and you'd like to go back and access the recording, you can use that same Zoom link that you're using to join today's live presentation to also access the recording. And then just remember that the recording is available for 60 days. And then we do have an additional security measure in place. So we want to protect Dr. Sesta's information here. And you may not believe it, but there is a black market out there for webinars. And so there are- There is. There is. Dr. Sesta is well aware. So there, we just wanna make sure that we do protect her information, of course. So when you click on that Zoom link, it will prompt you to enter your information and that will just send an email to us to validate your recording access request. And we approve those requests very quickly, typically within just a few moments of receiving them. But we ask that you give us one business day to approve those requests. And then once that has been approved, you will receive a follow-up and final email from Zoom that just lets you know that the request has been approved and we'll give you the link to go directly into the recording. And then just something that I've seen recently, for some reason, in the recording layout, the way Zoom has it designed, it can be a little misleading that it seems like when you click on the link, it's a white screen. And so it looks like there may not be anything there, but if you scroll down, then you should see the option there to play the recording. So I just wanted to give you a little tip there. I've seen several folks having trouble with that. And then of course, if you have any additional questions, you can always reach out to us at education at gha.org. We'll be happy to get those questions over to Dr. Sesta. And you see her content information here on the screen. I know that she's wonderful about being very thorough and timely in her responses when she does receive those additional questions. And then again, also linked in that email tomorrow morning will be the slides that were presented today. So if you do have any additional questions, please don't hesitate to let us know. Now I do see just several comments here in the chat, Dr. Sesta saying that it was a great presentation and very informative. And we do thank you, as always, for your time and information that you shared with us. And thanks so much for being here with us again after going through a not so great time with a recent surgery and for powering through. So we greatly appreciate that. We look forward to having you. Well, I thank everybody. Oh, thanks. I'm just gonna say I thank you for your patience with me. Yeah, no, absolutely. I'm glad that you were able to get those other slides up. And then again, if we have, if anybody has any questions, please don't hesitate to let us know. We look forward to having you all back with us next week for part three. And I hope you all have a wonderful holiday weekend and a great week. And we'll see you next week. Thank you so much. Thank you, Dr. Sesta. Thank you. Bye-bye, everybody. Bye-bye.

Dr. Tony Sesta

case management consultant

healthcare settings

two-midnight rule

patient admissions

medical necessity

alternative care options

Access point case management

patient care optimization

collaboration

readmissions

social determinants of health

program success measurements

RN case managers