started with part three this morning. Dr. Toni 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 more than 25 years. 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. Thank you for being back here with us this morning, Dr. Sesta, and we invite you to get us started with part three. Thank you, Lindsay. Hey, I can't believe it, webinar three. Welcome back, everybody. And Lindsay, they are troopers, as I think I said last week. Here we are in the midst of the holiday, spring holiday season, and we're getting lots of folks joining today, or maybe you're gonna be listening later, but thank you so much for coming back. We really do appreciate it. So today, today in webinar three, we're gonna talk about how you can relate most effectively with your physician advisors or advisors and your hospitalist. To me, those two physician groups are so key to our work in case management. And if you happen to be an ED case manager, we touched on ED case management in our webinar on access point case management. And so if you happen to be somebody working in the ED, obviously your role with your ED physicians is very important. So we'll just touch on that a little bit. And then I wanted to go over some of what I'm calling specialty positions. And these are positions that I have found over time enhance the productivity of the department and can make a huge difference. I remember back, and I know I date myself frequently, but when we were putting together some of these models, I'm gonna say in the 90s, I had termed the term dyad, dyad meaning two, of course. And at the time I called it the dyad model because we essentially had an RN case manager and a social worker, and that was my dyad, that was my case management team. Well, over time, as we've gotten more sophisticated, as things have gotten more complicated, as lengths of stay have shortened considerably, we began to add other specialty positions to the team of case management. So I wanna go over some of those with you today. Some of you may have some of these already in place, or maybe you're considering them. If you are an experienced case manager, you've been doing this a bit of time, sometimes these are nice promotional opportunities for you as well. So you can almost create a ladder, a promotional ladder in the case management department. So that's basically what we'll do today. So, as I like to say, we cannot perform case management in a vacuum. We have to work with the interdisciplinary care team, and certainly we have to work with each other. And what had happened years ago before we started with the dyad model or the triad model was taking the staff out of these silos and integrating them. And we've talked about that in our basic bootcamp. Pulling our leaders closer to the bedside, and I think I may have given the example of a hospital I consulted at in Massachusetts a few years back, and they had one leadership position, one director, and when she was off, there was no leadership. You can't run a case management department that way. Again, that's sort of a throwback to the old utilization review days. I was telling a colleague how we have a think tank going with some of us folks who've been around a while doing this stuff, and I said, we still have executives who, when they think of case management, they think of the old UR models of the 70s and 80s, and they don't really appreciate what case management can do when it's put together properly. So the leader is super important. The CMO, maybe, and then our physician stakeholders, such as we'll touch on today. And of course, of course, our other supports, nursing, ancillary services, the patients themselves, and of course, these specialty positions. So we can't forget, nursing, it's sort of like the last frontier for us in some ways, our nursing colleagues. But I think things are slowly, slowly getting better in that regard. So physician advisors. Well, I do like to tell my historical stories, and physician advisor is no less an old story. And the story is that some of you, and I won't ask you to raise your hands, but some of you may remember the days in which physician advisors were typically the physician, it could be a surgeon who had retired and wanted to just kind of stay in the game a little bit, wanted something to do, okay, so we'll make him or her a physician advisor. They weren't trained in how to do it. It was kind of specific to the person who took on the role. It was very loosey-goosey. And so it didn't get a lot of traction, typically. And that was pretty common. I remember going into hospitals over the years and the physician advisor was fairly disengaged and not actively participating. So we have seen a tremendous and positive change as far as that goes. And of course, it aligns well now with the Affordable Care Act, which, oh my gosh, has been around for quite a few years now which says we should be providing the right care to the right patient at the right time while avoiding delays, inefficiencies, inappropriate testing or treatment, excessive costs, and uncoordinated transitions of care. And we should be leaning on our physician advisors and other support in the case management process. Today, we see they're more integrated with quality management resource and utilization management. Obviously, that's probably the main thing that they do. Patient safety and regulatory compliance. So we can engage them on so many different levels. Well, I guess it was 2014-ish. The physician advisors, as they became more sophisticated, decided to launch the American College of Physician Advisors which I thought was a really great idea because now we take it away from just somebody who's post-retirement and wants to kind of do this and that. Post-retirement, who wants to kind of do this and doesn't really have a handle on how to do it. They have a website right there if you're interested in taking a look. And they collaborated with the American Board of Quality Assurance and UR Physicians to sponsor physician advisor specialty in 2015. So it's not that long, right? Nine years since physician advisors have actually been a specialty group. And that's interesting and hard to believe in some ways. And then we saw the creation of the National Association of Physician Advisors. Also, actually in 2009, so it preceded the other one. It was a response to the need for a way to network, for them to network and exchange information. And it became really a community. And then back then I remember hearing physician advisors say they're going to a conference, they're gonna take a class, what have you, which was really a really great thing and exciting really. There's tremendous value in the physician advisor role. The very first physician advisor I ever hired was a young guy who just had an interest in doing this and really paid for his salary three times over with the monies that he recovered or prevented from being spent, if you will. So much of what we do is cost avoidance. And so it's not that we bill for our services, but we certainly do participate in a lot of cost avoidance. So we prevent spending from happening. And yet here we are all these years later and so many hospital executives still don't really understand the role. They say, oh yeah, I think we have to have it, but I don't really understand what it is or what it's supposed to do or even how it can impact outcomes. And that's why it is important for you leaders joining me today to think about ways in which you can get back to your executives or at least your boss, talk about how your physician advisor is positively impacting not just on your department, but on the hospital at large. So we're gonna look at a tool later. It's just a very simple little tool just to give you an idea. If you have case management software, well, certainly there's ways in case management software to keep track of the productivity and the outcomes of your physician advisor. So there's lots of benefits in my opinion to this role. And when and if you need to write a job description or to improve maybe the existing job description, I just have here for you some of the things that you might wanna consider adding. So they should provide support for you and or utilization management. They have to have a working knowledge of case management and they have to have a type of personality that allows them to collaborate within your department. And so they have to work with obviously the RN case managers and social workers, but even more importantly, the denial and appeal staff and leadership. So they have to be present and they have to be visible on the units or an available by phone if necessary. It's really helpful if your physician advisor has credibility, clinical credibility, and that collaboration piece. They should be versed in compliance management, and they can be very helpful with that. And then as you work on your dashboard, your outcomes, which we will go over in our last webinar in this series, you can absolutely incorporate their outcomes as well onto your larger dashboard. I love that little pencil guy. I think he's really cute. Anyway. You want to look at transitions of care and how those might have been improved operationally and strategically. It's a really great thing if you're able to do it to have your physician advisor sitting in on payer contracting negotiations. That's really great if you're able to do that. And they can contribute to the operational and strategic goals through all of the things we're talking about here. They can do education. I don't think we think about that enough from our physician advisors. I mean, they're out there, they're educated, and they can certainly provide a role in education. I think the greatest value would be physician staff, because physicians, as I'm sure you know, physicians like to be advised from other physicians or educated from other physicians. So that is an important piece that they can take on. Or they can have, you know, those one-on-one strategic conversations with physician colleagues or groups as things come up or in a more professional, I'm sorry, in a more organized fashion. You can consider them to chair your U.M. committee. There is no written requirement for them to do that, but sometimes they are a good choice, maybe with a co-chair of the Director of Case Management. Of course, and we've gone over this quite a few times in our various topics, they participate, they must, if you're doing a Condition Code 44 or Part B billing, well, you've got to pull in the physician advisor and or a member of the U.M. committee. But typically, the physician advisor is the one most, again, most versed in the process and probably your best choice. Rounding on the units is really, as I said, they have to be visible. And so they can round, they can sit in on long lengths of stay meetings, they can help you with the two-midnight rule and OBS patients' lengths of stay. They can even tap in and out of different interdisciplinary walking rounds, which we have talked about, and we don't typically think of them as a member of the rounding team, but they could certainly pop in or out, particularly if there's a problematic patient that they want to participate in discussing. And they can even intervene on barriers to next level of care when that might, you know, be necessary. So this is that little spreadsheet I was just mentioning, and it's just very simple. And I just put here as an example the denials, because I think, you know, they're easiest to keep track of. So this is a denial management activity report, but specifically related to the physician advisor. So I have, if you look at the middle there, type of case, retrospective or concurrent, how many cases were referred to the PA, how many were appealed by the PA, percent of all cases appealed, cases not appealed, because certainly the PA can say, you know, I don't think this is worthy, and percent not appealed. And then on the bottom section, the final determination. So how many cases, how many days paid, percent not paid, and so on and so forth. And you can put the dollars in there, and that's where I got to the ability to say my physician advisor, let's say he, I don't remember his salary truly, but let's say his salary was $100,000. And in that year, he recovered $300,000 in overturning either concurrent or retrospective denial. Well, you know, that really does tell the tale, in my mind, because, you know, you don't get a return on investment that good very often. The other things for us to consider in terms of outcomes, again, did he participate in a secondary review? So these are not on my denial scorecard, but you can certainly, and you don't need to do this, you guys don't need to do this, let me say that. Certainly the PA, the physician advisor, can do this themselves. They should keep track of their own data, and then it can be cataloged, or they can do it concurrently. I mean, that's even better. If you have that case management software, well, they can certainly and concurrently enter their information. They may get involved with secondary reviews, avoidable delay interventions, absolutely. Maybe it's a delay in discharge associated with a physician. Maybe it's an inappropriate admission. Whatever it might be, they can certainly intervene on those, and you can measure that in a number of ways. One might be length of stay. So that direct physician intervention, and sometimes the physicians, you know, nobody's really pushing when there's sort of a lag in discharge, and so your PA can be helpful with that. And then, again, catalog your unnecessary admissions or readmissions as well. Again, that's something the organization is going to want to look at. There's a couple of different ways this can be organized, and you might have that internal physician advisor, as I said. They might be full-time or part-time. Maybe you just have one full-time or part-time, or you might have multiple physician advisors. I've worked with one hospital that had, I don't know, 10 of them because they were also doing other things. In some instances, we see the hospitalist role combined with the physician advisor role. These are not approaches that I would necessarily condone. I would rather have the physician advisor be that specialty position, and that's all they're focused on, and hopefully working full-time. That to me would be the best. Some of your hospitals, maybe they can't get a physician advisor or there's some other reason for it. They contract with a company outside the hospital. Well, let me hold off because on the next slide, we'll go over some of the pros and cons of that particular approach. The only good thing about being able to access external physician advisors is the fact that if you have one full-time PA, he's not working seven days a week. What do you do, one, on those days off, and two, off hours, maybe something comes up in the ED or something like that? That's when you want to tap into that external physician advisor. The hybrid approach is, to me, the best way to go. Let's look at how you might best consider this if you're looking at this. Best practice, internal PA, they have greater credibility with the hospital medical staff. You can get to them much more timely because they're physically in the hospital. It's always better to have a face-to-face, in my opinion, than a telephone conversation or even a text message. Not my favorite for this kind of work. Then they're around, they're visible. We already just discussed that external PA, adding that other layer of support. Sometimes when you have that external PA, the physicians may not be available at the moment when the external PA calls them, or they may not want to take the call. They may find it intrusive, or they don't know who this person is, or they don't know what to say exactly. That's problematic. They may not just respond in a timely fashion. I've seen it. I've absolutely seen it, and I'm hoping that maybe you have seen how that doesn't work particularly well when that external PA is trying to get to that physician. Getting subjective responses from the external PA that may differ is an issue, too, because you might call one time and get one PA and another time a different one. The continuity, the consistency many times is not there when you have that external company. For you guys, you have to understand what the physician advisor's role is so that you can understand when you need to escalate to them versus when you need to escalate to your departmental leader. You don't want to make the mistake of calling the physician advisor all the time when you don't need to go to that level of intervention, but you do need to know when you should. If you're talking to a physician of record and you think you need to escalate to the PA on the issue, whatever it might be, again, and we've talked about this before, but I just want to reinforce that you don't want to make this seem like a threat, like, oh, I'm going to go to the PA. You want to just use it as a collegial opportunity to resolve a conflict of decision-making between you and that consulting physician or attending physician. And then you need to understand how important your documentation is regarding avoidable delay. And again, if you're the one cataloging that versus the physician advisor, you want to get that in there. So we've looked at this before, but let's look at it quickly again. This is the patient who doesn't meet medical necessity criteria, and you're going to discuss that with the physician of record, and as we've talked about, you're going to ask for additional documentation. The physician says, I don't have any additional documentation, and so now you say to the physician, you know what, why don't we get the PA involved so we can figure out what to do going forward? And then you make that referral. The physician advisor then is going to make a recommendation in concert, of course, with that attending physician. It also kind of, you know, as I said before, breaks the tie, but also, you know, the physician advisor talking to that physician about documentation can help, too. Not every physician needs that level of intervention, but some do. Of course, you want to educate your physician advisor. And frankly, if they're going to outside conferences, if they're getting certified, if they're doing any number of things, they're going to be pretty well educated, but you also want to make sure they are educated on your department and how your, you know, what your expectations are specifically. Whether they've had previous experience or they're new to the hospital or they have no experience but they've been on the medical staff, you know, you have to gear your education accordingly. They may not need orientation to the entire hospital, but they do need to be oriented to the department. So a manual is helpful, but other ways of educating them are also helpful. I always like to have my PA attend staff meetings, and that's another way for them to get a little more educated and get more familiar with the other staff members. And then, of course, resources, like the American College of Physician Advisors or even conferences, as I said, are, you know, all great ways to get your PA up to speed. So collaboration, best practice strategies would include intervening on the two-midnight rule, all the things I just went over, payer communication, denials and appeals, and so forth, hospital collaboration, as we talked about, and going beyond just our department, going beyond our physicians. They should have working relationships with finance or compliance, ancillary services. And again, have them, if you can, sit at the table when these managed care contracts are being negotiated. The director of case management and the PA should be sitting there because if they're negotiating on the utilization management component of the contract and they're, what shall I say, they're making promises, and you don't even know what those promises are, that's very problematic, or issues aren't brought forward during the negotiation process. That's unfortunate because that's ammunition for the hospital to use to say, look, you know, this isn't going quite the way that we would expect, and here's the data to show you where we have specific problems. I mean, that gives you some leverage on those negotiations. So the physician collaboration should include an ability to establish that expertise and credibility with the medical staff. So that's an ongoing improvement process, one-on-one perhaps, or as I said, maybe it's meetings of some sort. You want to have that right personality in that role, and I'm finding more and more physicians are attracted to this position, and they come with that right personality, and they need to understand it's not a desk job, you know, we're not going to send you a case and you're going to sit and look at it on your computer. It is, you know, walking around, going to the nursing units, and focusing on specific people. They can assist the case management department in maintaining compliance with all the things we have here, and my goodness, hasn't compliance become a much bigger issue than it had in years past, and so having that intervention, sometimes it's a requirement with Code 44, for example, but sometimes it's just the better thing to do. Again, intervening with patient flow or delays in patient flow, delays in discharge planning, and if you're going out and you're meeting with different post-acute providers or they're coming in for meetings, you can have the PA there for those as well. And, of course, with anything, there are some challenges for the PA. If they're new, there's a lot of information they have to learn pretty quickly and absorb pretty quickly, so you have to give them that time, you know, to get up to speed and become an expert at many of these different topics. It can be a challenge when there's also an external physician advisor for your internal physician advisor. I don't think that's a big deal, but it certainly could happen. And leaders, you want to make sure your departmental staff are ready for that physician advisor. They understand what they need to know and when to call upon that PA. So, again, put them on your dashboard. Look for performance-improvement responses. So, in other words, you know, when we talk about outcomes in Webinar 5, we'll look at how we can look at trending of our outcomes and where performance-improvement opportunities may lie. Collaboration, hard to measure some of this stuff, but, you know, it's something we want to hold them responsible for. Whether it's your, and particularly your utilization management plan, you want to make sure their role is included in that plan or other policies or protocols where the PA gets involved. Prioritizing the day and executive leadership also. Other challenges for the physician advisor. They may be a little slow to pick it up. Hopefully not. Medical staff collaboration, as I said. You know, physicians, I remember back when physicians were all irritated about managed care. Today, some of them are irritated about some of the new payment models or how schizophrenic everything has become with so many different payment models and they may want to take it out on the PA. Hopefully that's not the case. Some of the new payment models, you know, are really geared at whether it's a bundle payment or readmission reduction or an accountable care organization. We want to keep the patients out of the hospital. So that may be a concept that may be a little bit difficult to understand. And then I just wanted to mention the efficiency measure. We've talked about it before. The spending per Medicare beneficiary measure, which looks at your hospital's cost and length of stay. My goodness, what an advantage you can have if your physician advisor is getting involved to help you with those kinds of things. So he or she can help you to manage resources during the hospital stay by, you know, again, intervening on some of these delay issues, whether it's length of stay or cost. Or when we see a physician, you know, the complementary colonoscopy, as we like to say, when they're ordering things unrelated to the admission diagnosis and or we see avoidable delays, when the physician advisor intervenes in that kind of stuff, well, they're helping you to manage your length of stay and cost. They might help you with care transitions or improving those. Card wiring, your multidisciplinary teams can help with your efficiency measure, helping with discharge planning and reducing readmissions. All of this stuff will help improve that efficiency measure. And I think the efficiency measure is one of the measures that most closely relates to the work that we do. So as I said earlier, the physician advisor should be a member of the UM committee, if not the chair of the committee. And that's really would be my preference to have that PA. If, you know, if they're a functional and knowledgeable PA, have them be the chair. And that's certainly a question you can ask during an interview process to see if, you know, this person's going to be the right one. The optimal agenda for your UM committee will improve committee collaboration. And I really do think that when you've got a physician as chair, it will engage other physicians to participate more greatly. But the director, because you're the one looking at your scorecard, although your PA should as well, you can really drive your agenda based on your scorecard or conditions of participation expectations. And that really is very helpful. Now, if you do have external physician advisors, either part-time or full-time, you want them on your UM plan too. And they should be listed as committee members. So they could be included through telephone or what have you, or Zoom as a committee member. And that should be in your plan. All right. There's our physician advisor colleagues. The other group of physicians, let me just take a sip here. The other group of physicians that is really critical to our work as case managers are our hospitalists. The 28th anniversary of the hospitalists. Doesn't seem like it. But it's true. And prior to having hospitalists, physicians, the way they practiced was based on a patient's age or age group, anatomical or physiological symptoms. And they still do that, obviously. Or they might be a laboratory physician or radiology physician. And that was pretty standard. So hospitalist medicine introduced the first time that a physician's focus was on the location in which the care is delivered. So this was a big change. And something quite new. Originally, when this started 28 years ago, they were focused on length of stay, cost, and readmission reduction. Although readmission reduction wasn't as big a deal 28 years ago as it is today. So things, you know, things progress. And today we have 50,000, probably more, hospitalists nationally. It's larger, it's a larger subspecialty than any other subspecialty in internal medicine. Just imagine that. Seventy-five percent of hospitals have hospitalists. It's unfortunate when I go to a hospital and they don't have hospitalists, because I remember the beginning of hospitalists. I really do. And I remember thinking, this person, the goals of this job are aligned with case management's goals, more than probably anybody else in the hospital, other than maybe the PA. And so look at how their current focus areas align with what we do. Length of stay and cost reduction, readmission reduction, quality of care, and even patient satisfaction. These are things hospitalists are being held to account for, and they're so consistent with the work that we do. And so I said, this person, this role will be so integral to case management. Well, unfortunately that didn't happen universally. We saw some hospitalists that got very siloed and really didn't see the opportunities in front of them in terms of collaboration. Hopefully, and I think this is specific maybe to a hospitalist group in a hospital. And the leader of that hospitalist group, because sometimes I've also seen amazing collaboration. So it can go to either extreme. Some physicians are attracted to this because, you know, they know what days they're working. They're no longer interested in primary care, internal medicine. And this is a different kind of a job. And the whole idea was to let the community physician stay in the community, not have to come into the hospital, saves the community physician time. And then the hospitalist, on the other hand, is well-versed in how to manage hospital patients and how to expedite care for hospital patients. Because think about it, the community physician comes in in the morning or whatever, makes rounds, and then they're gone. So the hospitalist is there to really coordinate the care. That, again, was the logic for the position. We also are seeing subspecialty hospitalists in these different areas. So that's kind of cool, too. And they've become leaders in quality improvement efforts. And I just thought this was a little anecdote that was interesting. There was a U.S. Surgeon General and a chief medical officer for CMS who were hospitalists. So not only maybe they were hospitalists before, and now they've even moved up into these very high-level positions. Not unlike our physician advisor, we really do want to see an interdisciplinary approach and collaboration between you guys and the hospitalists. And you have a great opportunity to have a partner in crime in your hospitalist staff. Now, one of the downsides, and I don't remember if I have this on a slide, but I'm going to mention it now anyway. When you've got your hospitalists running from unit to unit, because that's really the old paradigm of the community physician, right? The community physician came into the hospital, or still does, and he might have one patient here and one patient there and what have you. And when hospitalists came in, they kind of followed that same idea of continuity of a patient regardless of where that patient was in the hospital. The problem with that, I mean, and there's pros to that, don't get me wrong, but the negative to that is that you don't have the hospitalist on that unit working with that interdisciplinary team. They come and they go, they're like a visitor to the unit, and you miss so many other positives that come out of that hospitalist being unit-based. So if you've got your team, including case management, and then you've got a unit-based hospitalist and maybe you've got a unit-based physical therapist, oh, my God, you've got, you know, really the dream team right there. So I'm not a big fan of hospitalists running around the hospital. It's also less productive, and they will tell you that if they're honest. So when they work with you, what you're trying to do is apply best practice in the clinical interventions to reduce variation. Again, a hospitalist understands that and should participate in that. They can also focus on those long length-of-stay patients, so they should be sitting in on a meeting, if you have those, to give their perspective and troubleshoot and try to come up with some solutions. They certainly will also help with decreasing denials and improving revenue. These are all things that, particularly denials and costs and all this and length-of-stay are things that they're held to account for. Breaking down silos, again, helping us foster that interdisciplinary team, but they have to be there. Care redesign, maybe if you're redesigning some things in the department, you might want them to be involved because, again, you know, they're close to the action. And they should be looking at resource consumption. If you have a readmission team or teams, really good idea to have a hospitalist involved in that. You know, they're drivers for a lot of these issues that come about with readmitted patients. Maybe also telling you on discharge, this patient's going to be at risk for a readmission and working out a plan that maybe reduces that risk. And that would also include working with the ED physicians when there is a potential readmission coming in through the ED. That's also a really good strategy because that's, again, that physician-to-physician conversation. We're also seeing some hospitalists staffing post-acute care facilities. Isn't that kind of cool? Improving care coordination between the inpatient and post-acute worlds. Continuity, so if they're going to admit a patient from a post-acute facility, for example. And then they can also help putting that patient in the right status when they do come to the hospital. I like that, too. Like anything, again, we have challenges for our hospitalist group as well. You know, there can be so many different physicians involved, but if you think about it, when you've got a hospitalist versus a community-based physician, you've got a little bit more control over it and maybe a little deeper relationship. That will reduce the likelihood of miscommunication or bad handoffs or lack of coordination. Next week, we're going to talk about transitions in care, and we'll talk quite a bit about this particular issue because it has become a big focus of attention. So I've devoted a whole webinar to transitions in care, so we'll do that next week. There's gaps, too, between your community-based physicians and your hospitalists when there isn't a good relationship or good communication stream between them because if the hospitalist admits a patient from the community, they should have a conversation with that patient's primary care provider or specialist upon that admission. So those gaps can be problematic, and the same thing can happen if there's poor handoffs. Community physicians may not know that certain tests were performed before the patient was discharged, and therefore they don't know to look for those results, and then they're not following up on those results if they're critical lab values, for example, or they're not following up on treatment recommendations. So sure, they can read the medical record, but a handoff, even a written handoff to the primary care provider or a summary or something like that with this kind of information, very, very helpful. So the physician involved in the outpatient side of that patient's care may be feeling disconnected because if you don't have that communication back and forth and or discharge, that's going to create some discontent for that community-based physician. Patients, you know, they don't know the hospitalist, and so they may feel like they don't trust them entirely. They've had their community-based physician for, you know, 25 years. They trust them. They know them. And now they've got this person they don't know, so it's important to help the patient understand that, you know, there is a relationship, hopefully, between their physician on the outpatient side and the hospitalist so that their anxiety can be reduced somewhat. And over time, when a community physician does not come into the hospital, well, you know, they're going to have a reduction in their expertise. But that's okay because that's where the hospitalist drops in. And hospitalists may be less focused, you know, and I hope not, but on the patient's continuum. So where did that patient come from? Where are they going? What kind of resources? You know, some of that is related to discharge planning as well, but, you know, they should be thinking about those sorts of things. So it can be a bit of a challenge to make sure you do have that non-fragmented care, and it does all come down mainly to communication, handoff communication, and just conversation. You can see hospitalists fall into a shift work mentality. It's 5 o'clock, I have to leave kind of thing, which is unfortunate if that does happen. They could potentially transition their loyalty from the patient to the hospital, and again, we hope that doesn't happen, but if they are focused on the goals of their job or goals of the hospital, that's going to improve the patient's care at the same time. Community physicians may be starting to relinquish their hospital privileges, and so there may be less medical staff physicians. You know, and sometimes you do need community physicians to get involved in decision-making with the hospital, less physicians to take leadership positions, medical staff leadership positions, and I think, you know, we're not there yet as far as these potential challenges, but they could be coming, and this loss of a voice can increase that gap. So it really requires us to really proactively think about how to engage and bring our physician colleagues in the community on board. Hospitalists, they are going to be held to account on some of the value-based care metrics, and so that might be frustrating for them. You know, they do have to keep a lot of balls in the air, that is for sure. When they rotate off, I hate when they rotate off, I don't know about you guys, but, oh my gosh, you know, again, poor, poor handoff sometimes. So maybe they rotate on for two weeks and off for two weeks, and when that new group comes on, they don't know a thing, they haven't gotten good handoff information, or maybe they haven't really bothered to learn it, but I think that is potentially a big problem in the making, and so, you know, we do try to work with physicians to improve their handoff communication. We talked about that in webinar one, when we talked about rounding and handoffs, that's so important. Hospitalists may sometimes be out of network for your patient, or your, you know, obviously that can be problematic, and of course, like any professional group, they can experience burn out. I'll take another sip here. Oh, that was good, I just spilled my coffee. One second. All right. So they've evolved in terms of their scope of services, so we see sometimes that they're focused on the ICU, short stay unit or observation patients, as we talked about post-acute care, palliative care, palliative care, I like that, and outpatient, interesting, right? So outpatient, one of the areas where there's been some work has been in what they call post-discharge clinics, post-discharge clinics. I don't know if any of you have had experience with these. The primary goal of your post-discharge clinic is to reduce readmissions. So the timing of your post-discharge physician visit, which might be delayed, is a key factor. So in other words, patient gets discharged, they can't get an appointment in a timely manner, we all know the drill, and they wind up getting readmitted to the hospital. So this post-discharge clinic can help with that. So CMS has recognized this issue because now they have two transitional care management codes, which allows for increased reimbursement for the, and that's physicians I should have said on this slide, that's MDs only for those two transitional care codes. I've had some case managers ask me about that, and there aren't any codes for us yet. These are physician codes, billing codes. Some of the areas in which we've seen these post-discharge clinics, a big one, safety net hospitals, where you have a high Medicaid population, but also academic medical centers. And they may focus very greatly on readmissions, patients with noncompliance issues, patients with poor outcomes, and I would add again, patients who can't get an appointment, with their physician in a timely manner. I don't know if you've heard of this title, extensivist. This is an example from Care More Health System, which was published in 2017. So they called the extensivist, you have to think before you say that, extensivist post-discharge model. Extensivist post-discharge model. So they expanded the scope of their hospitalists. They used a primary care multidisciplinary team coordinator. They had a panel of 100 patients. These included the sickest 5% of the Medicare Advantage insured population. So they focused on Medicare. And they followed patients across all care sites on the continuum. So they had these 100 patients, they followed them, medical, the physicians, this person, extensivist, followed them across the continuum, regardless of where they were. So this was a shorter period of time after discharge. And they found it worked quite well, decreasing readmissions and decreasing length of stay. Something like this would be a good strategy, frankly, for an accountable care organization or a bundled payment model. I could also see this working quite well with case managers. The hospitalists may not intuitively understand the positives of working directly with case management. So we want to remind them that we have like-minded goals. And to keep that in mind in terms of working as a team. Because we are both employed by the hospital and we have shared goals. This is always my hope for hospitalists. And I hope some of you are experiencing really good relationships that way. So for our leaders today, just a couple, I think I've got a couple of slides, three, four slides for you all. So you want to look at your strategies to impact your value-based reimbursement strategies as it relates to the use of your hospitalists. Make sure you put your discharge date on the whiteboard and walking patient rounds, as we've talked about. You want to have your afternoon stand-up meetings with your hospitalists and department staff. When we talked about having the afternoon huddle, you have rounds in the morning. Now, again, you can't have your hospitalists at rounds if they're not unit-based. So that's another good reason for why you might want them to be unit-based. And hopefully they are and they can attend morning rounds and they can attend afternoon huddles or afternoon stand-up rounds or meetings. Leaders, you want to make sure you're cultivating a working relationship. You should meet with your hospitalist group or leader on a monthly basis. You want their input on strategies to address length of stay and patient flow and all the other things that we have been discussing today because their input will be very valuable in helping you with the department. So in the monthly meetings, you want to bring your dashboard. You can even, and this can be a one-on-one data sharing of individual hospitalist outcomes. Hopefully the leader of the hospitalists is doing that and together you can discuss the performance of some of the perhaps more problematic hospitalists. If you have any updates from CMS or payer contracts, you know, you can discuss those and get feedback from the hospitalist group. You may want to bring specific directors to a hospitalist meeting. Maybe there's issues in radiology, MRI, as I have here. You want to make sure you introduce and welcome new hospitalists and introduce them to the case management department staff and also discuss any operational changes that you might have in your case management department. If you find any of your staff who aren't collaborating particularly well with the hospitalist team, then, you know, you want to intervene and re-educate them. You want to make sure any new hospitalists understand the processes and you want to engage them as early as possible. Working with the, either the leader of the executive, I'm sorry, the leader of the hospitalist group or the executive leader over the hospitalist group is important as well because you really do want to get as much out of this collaboration as you can. I say this all the time. You can never communicate too much. I believe that to be very true and you have to tell people something seven times, I think it is, before they take it in. So the more times you communicate, the better. Ask for, so this isn't you talking at the hospitalist team all the time. You also want to get input from them as well. And if they're unit-based, they can become a member of that team and that's really a great thing. When you can, you want to audit your hospitalist and case management collaboration. That's kind of tricky, a little bit difficult to do, but if you can, pull that maybe from your medical record. So did I say it enough times? For you to encourage unit-based hospitalist assignments to foster collaboration, I truly believe that that is critical. Okay, let's talk for a minute about our emergency department physicians. We've talked about them when we talked about access point case management and we discussed having the appropriate coverage in the ED so that you can collaborate actively and timely with the ED physicians, particularly to manage status orders. That's such a big one right now, whether the patient's going to go inpatient or placed in observation. But you also want to work with your ED physicians in terms of prioritizing patients, expediting care, preventing a readmission. We really do want to see you interject yourself in the admission process. And by that, I mean if that physician is considering admission. Now, most hospitals that I've been to have the ED physician makes a recommendation for admission, but it's either the hospitalist or somebody else who actually admits the patient. At some point in there, that's where you want to interject yourself. Make sure that you agree that that will be the right level of care before that order for admission has been put through. That is really the crux of how you can help to manage the two-midnight rule optimally. And then you can prevent readmissions at the same time. Unnecessary admissions that may not be related to a readmission, but they're just an unnecessary admission. So lots of benefits to having case management in the emergency department, but to work so closely with our physician colleagues. And if you've got one hospitalist who does admissions, there's another working relationship that's going to be key. And then you have your high-volume admitters. When you're looking at data, particularly as it relates to physician behavior and performance, you're going to have maybe some outlier physicians with long lengths of stay, but small volume, meaning they don't admit that many patients. They are barely bad about their length of stay, but they don't have a lot of admissions. And then you're going to have your high-volume admitters. And they could be anything. They could be a medical doctor, a specialist, a surgeon, anything, right? But they're high-volume. And sometimes these guys are untouchable. Orthopedic surgeons, cardiovascular surgeons, neurosurgeons sometimes, excuse me, sometimes are considered untouchable because of the volume of patients that they admit. But nevertheless, they may have some room for improvement. And if you do it politically correctly, you can positively impact. But you can select a group to start with that's willing to collaborate. Maybe you have a high-volume physician or group, but they have high cost and length of stay, and they're willing to work with you. I mean, maybe their issues are manageable or fixable. It may not all be just physician performance. So it's an opportunity for you to look, particularly leaders, and then trickle that down to the staff. If you pick a group and they're willing to participate, you don't always want to start with the squeaky wheel. Let me just say that. You know, you've got a doctor maybe who's a high-volume admitter with a high length of stay, and he's a pain in the butt. I mean, I know that's not a professional term, but you may not want to start there because you really do want to start where you might have some success. So you want some willing participants. That's kind of, you know, a template for any performance improvement project. So just, again, some critical strategies. And if we think about our main roles that we talk about all the time, and we think about these, let's just, you know, look at how we can work most collaboratively. So under our role in utilization management, we want to engage our physicians in terms of their expertise so that we have the appropriate treatment plan and, of course, the appropriate level of care. And for our expertise, we would know which health care options would satisfy that physician's treatment plan and to help to support the appropriate treatment plan. So this gets back to a talk we've had about medical necessity. So once we have the physician with the right medical necessity, the right plan of action, we're there to optimize and drive that plan. I also wanted to share with you something called choosing wisely. When you start to talk about best practices and managing resources, you know, you do have an option or an opportunity in your electronic medical record to put standards of care by using different guidelines, if you will. And under that guise, I just thought I would share choosing wisely. I gave you their website here as well, if you want to take a look. It's all free information, and their stuff works for both patients as well as the physicians or other clinicians. So if you're looking for information that's supported by evidence, that's supported by evidence, not duplicative, they're looking to do that, free from harm and truly necessary. That's really what their mission is, to provide you, to choose care that meets those four outcomes. So they've been working on this since 2012. They've asked national specialist organizations to identify tests or procedures commonly used in their field whose necessity should be questioned. I remember one of the early ones I worked on way back in the, oh gosh, somewhere in the mid-90s, was doing a daily chest x-ray on an improving pneumonia patient. I mean, that was kind of what everybody did, and it was a waste of resources. So things like that. You may have a question about that, and you can go to the choosing wisely website and find out if, you know, if you, if you're right. So this empowerment helps you to figure out what's right in terms of tests and procedures, and it's a really great way to manage cost and quality. Now on the patient side, I thought this was kind of neat. They give five questions to ask your doctor before you get any test, treatment, or procedure. I mean, this is a great patient education tool, or something you can certainly give them on discharge, and go over it before discharge. Do I really need this test or procedure? What are the risks? Are there simpler, safer options? What happens if I don't do anything? What happens if I don't do anything? How much does it cost? And of course, detail with, with each one of those. When patients go to the doctor's office, we've all heard of, of white coat syndrome. You know, patients get very anxious. They don't always ask all the questions that they should ask. And that's why over the years we've encouraged patients to go with another person and to write their questions down in advance. So this is something they could just bring with them routinely. And they might not think to ask, I mean, I ask these questions, but your average patient is not going to think. Question the physician to ask any of these questions to be worried about certain things like risk. They just probably wouldn't think of it. So I see this as a great patient education tool. So for the hospitalist who's caring for adult patients, they give you guidelines. And I think everybody's pretty familiar with this one now, right? Don't leave in place urinary catheters for convenience or incontinence. Don't prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications. You know, without guidelines like this, I mean, it can be hard to question the use of certain resources. Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds. In the absence of active coronary disease, heart failure, or stroke, don't order continuous telemetry. This is one of my favorites. Outside the ICU without using a protocol that governs continuation. We all know if we get a patient put on tele, they never come off. And then you got people who need it, who can't get it. And so again, we, case management, can provide an opportunity to intervene when we don't think that patient needs it based on a guideline that should be developed. And you can work on your cardiology department on that. Don't perform repetitive CBCs or chemistry testing in the face of clinical and lab stability. That's kind of like my X-ray on a pneumonia patient. For ED physicians, avoid CT scans of the head. In ED patients with minor head injury, oh my God, how many times did they just rush to do a CAT scan or an MRI? Avoid placing indwelling catheters in the ED. Don't delay engaging available palliative and hospice care services in the ED. I like that too. And case managers in the ED and social workers, that's something where you can intervene on behalf of the physician and the patient. Have that conversation with the ED physician and say, you know, I would like to see if we can get palliative care to come down, or I think we need to talk about hospice care, whatever the issue is, if you have the patient with you long enough to do that. Avoid antibiotics and wound cultures in ED patients with uncomplicated skin and soft tissue abscesses. Okay. Okay. So that was just a small snippet of what you can get out of the Choosing Wisely website, and I do hope you'll take a chance and take a look at what they have to offer. Again, no charge. So as I said before, we started off with these, quote, dyad models. I coined that phrase way back, and today we know it takes creative and unusual and different roles in order for us to get all of the work done that we have to get done, to allow you guys to work at the top of your license. You've heard me say that before. I don't want you getting bogged down with paperwork and clerical work. I think we're one of the last disciplines that is expected to be their own clerical staff, and I really do take exception to that because it diminishes our role, it diminishes our professionalism, and really, you know, doesn't allow us to get to the patient where we can be most effective. So we do want you to work at the top of your license. We have to respond to new regulatory changes, and that sometimes means a change-up in terms of who's doing what in the department, and sometimes we have to be a little more creative when we have organizational or departmental outcomes that we have to achieve. So adding case management specialty positions has become, in my mind, really important, and so these are some of the ones that I'm going to, well, these are the ones, excuse me, that I am going to talk about now because each one of these brings different value to the case management team, and as I'm staring at them, I feel like, well, there's a couple that could be a little optional. I'll talk about them, but generally, most of these are pretty necessary these days. So the discharge planning specialist position. This is, you know, such a great opportunity. How many of you struggle every day with one patient, let's say one long-length-of-stay patient, one complex patient, one difficult-to-discharge patient where you get completely sidetracked and absorbed with this one patient? While you're doing that, what happens to all of the other more routine discharges? Well, they get delayed. So the whole notion of the discharge planning specialist, and again, titles aside, I've seen other titles for this role. These really time-consuming patients are transitioned to the discharge planning specialist, and that allows the RN or the social worker to discharge or transition the more routine patients more timely. So there's a number of different ways you can identify which patients will belong with the discharge planning specialist. It might be patients exceeding your hospital's self-selected long-stay threshold, because remember, CMS does not give us a threshold for a long-length-of-stay. You guys in your hospital or your department determine what that is. So we've talked about 5 days, 7 days, 10 days, whatever you select. Or it may be a patient you're expecting is going to have a long stay, and you can pick them that way. But many times it's, you know, a legal issue, an undocumented person, a police issue maybe. You may need to bring in a community liaison. I certainly did that quite a bit when I worked in New York City because we had patients, you know, that were uninsured or undocumented or what have you, and we could get help from a community liaison sometimes. But the discharge planning specialist will take care of those long-stay patients. They have to work in collaboration with the RN because the RN is still doing clinical reviews and all that, and I should say this is usually a position filled by a social worker who's really versed in discharge planning. And then over time, as they do this specifically and only, they become even better and better at it, and it becomes a really cool role. I worked with one hospital that combined the job to two positions, one RN and one social worker. So the RN was focusing on the really complex, clinically complex patients, and the social worker on the psychosocial stuff. And that worked really well too, but you'd have to have a pretty big hospital, I think, to justify having two positions. So if you don't have somebody like this, this is something I really recommend because I don't think there's any hospitals these days that don't have this issue. It used to be a spattering of hospitals across the country that had these kinds of long-stay patients. I think all of us have these patients today and would benefit from this discharge planning specialist. I did have one hospital that had a part-time discharge planning specialist because they just didn't have the volume, and the other half of the time, the person, I'm trying to think, well, they had another position that they also performed. So that's okay too. You have to really base it on your volume. So you need to do sort of a pre-hire analysis of the kinds of patients that you think would be assigned to the discharge planning specialist. And based on that, you can figure out, and they can take typically up to about 20 patients. I think that's really kind of a cap on that caseload. When we talked about access point case management, we talked about these roles, but I just wanted to go over them again. I have to tell you, particularly as we talk about ED case management, I don't think you can have a proper case management department without ED case management. Folks used to consider it optional back in the day. It's not optional anymore. It's just that it's not an option anymore. It's really something you have to have to be able to do the work that needs to be done in today's world. You have to know your access points. We saw how many of them there are. You want to make sure the patient gets in the right level of care, providing alternative care where necessary. You want to make sure the hospital is going to get paid. I mean, that's part of what we do too. Save time and money by preventing the patient from being placed in the wrong order in the hospital bed or discharged. So again, for our ED case manager, the first type of access point case management, it's a gatekeeping role. We're really at the front end of the admission process or pre-admission process. They also facilitate patient flow in the ED. You want to manage that patient through the ED as quickly as possible, but you also want to optimize that time by getting things done that can be done. Interface with the rest of the team. Work with the physicians. We just talked about that. Intervene early, as I said, on those patients not meeting medical necessity. I know that most of the ED software does have a, there's different ways it's labeled. It could be like pending admission or physician considering admission. I saw that in one hospital. That's a great place for the physician to put that there. And that's for case management. And they can tell you verbally certainly as well, but you can see right there, okay, this is now where I have to interject myself because the physician is considering admitting this patient. I have to take a look and see what level of care is gonna be the right one for this particular patient. And then working directly, of course, with the physician. Appropriate transition of patients, perhaps out of the ED, and meeting for compliance. So again, that utilization review and collaboration with the physician. So you're gonna do your homework first. You're gonna do that review. You're gonna try to figure out whether or not the patient is gonna be in that correct level of care that the physician has ordered. And that compliance with medical necessity, of course, is what you're looking for. If a patient is admitted, but they're still in the ED, you can do an intake assessment. You can maybe even start to develop a patient-specific care plan. Again, assuming you know what the plan is in the ED. You're gonna look at tracking things like avoidable delays, variances, quality issues. You may be the one coordinating transfers from institution to institution. And then those frequent flyers that we talked about, those potential readmissions or patients frequently seen in the ED. You wanna kinda stop that pattern. So in terms of that gatekeeper role, you wanna make sure you've got that right level of care, right order, and right medical necessity. You also wanna put your discharge planning hat on and consider alternative care settings or levels of care. You want the ED physician and admitting physician to have a conversation if you can make that happen. Provide info to the physician as appropriate. And there's your physician advisor. Again, you may need to pull the PA in on certain cases. Okay, you also, some of these are repeats, but the third bullet, you wanna respond in a timely manner to requests for concurrent clinical information. Again, should that patient be held in your ED? So you're gonna have a subset of patients who are admitted, but they're being held in the ED, awaiting a bed, and you know that typically happens in the early afternoon before the discharges have left. And so you may need to do a concurrent review, and you may not have a lot of information available to you at that point, but you try to do the best you can with what information you do have. When you put your discharge planning hat on, you wanna think about those alternative settings. So when that patient doesn't meet a medical necessity for admission or maybe not even observation, there may be an opportunity to transition that patient home, maybe with other services. And that's always something you should be looking to do. Arrange for follow-up appointment. Again, patients are given a card when they leave, and they're told to make an appointment. They may not even look at that card for two weeks. They may not look at that card at all. They may just forget about it. And if we make the appointment, and again, this would be a clerical function, but if we make the appointment, then we know the patient has it, and hopefully we increase the likelihood that they're gonna actually go and see the doctor. So in terms of care coordination in the ED, we're gonna see a collaboration with our social work case manager to facilitate and expedite those patients. So sometimes it'll be the nurse, and sometimes it'll be the social worker working on those discharges. Expediting the diagnostic tests, treatments, and other therapeutic interventions for that ED patient falls under the social work case. So we're gonna see a collaboration with our social work case manager to facilitate that collaboration. And then we'll see a collaboration patient or family circumstances, or any other situation that's going to interfere with their care or discharge. Patient flow strategies. You know, the ED is required to keep data on ED throughput, ED length of stay. You know, hopefully our interventions actually do help improve that. You may start your inpatient assessment if that patient, or observation service patient assessment. In terms of resource management, one of the big ones, of course, are those frequent flyers to the ED. You know, you want to put together a plan that the ED team also is aware of, so when that patient arrives, you know, there's a different way of approaching that patient and dealing with that patient and preventing an admission of a patient who would benefit from alternative arrangements. All these things help to reduce resource consumption. We talked also about how to prioritize patients or how to triage in the ED, and these are a few other reasons other than what I gave you in our first webinar on access point case management that I thought you might want to take a look at. So, of course, you've got your readmissions. Did they have a treat and release episode in the last seven days? Let's see, what other ones didn't we talk about? I think we did actually cover most of this. ED visit from a SNF, because you wanted them to go back to the SNF. Social determinants of health issues for our social workers, you know, patients come into that ED and there's some big glaring issue that has to be addressed, and I think I mentioned before about looking for specific diagnoses of issue in your hospital to focus on. Yeah, it's probably going to be the readmission reduction diagnoses that we are held to improving through CMS, but you may have some other patient group that is equally problematic that you, you know, want to take a look at before they get admitted. And then the other type of access point case management is the admitting or transfer department case manager, and this is also a gatekeeping function, but it's for planned, urgent, direct admissions and transfers in. So we've talked about back in the day, this used to be a person in the admitting office, but as we've seen many hospitals develop transfer centers, there's an opportunity now to have this person cover both admitted patients as well as transfer patients, and they can be in the transfer center, they can be in the admitting office, wherever you think you're going to get the greatest value in having them physically sitting someplace. A little more water for me. So, they're going to do a screening of potential admissions or transfers. You're going to take a look at, you know, their medical necessity requirements. When you don't have a good match there, you know, you're going to talk to the physician. Same thing, same idea. It's, you know, it's something we don't always think about for non-emergency patients for some reason. You know, to gatekeep the other patients is just as valuable and just as important. And care alternatives. Again, pulling in the physician advisor where you may need to do that. And assess for inpatient-only procedures, as we talked about. We still have that inpatient-only list, but we may be seeing that ratchet down even further than it already has over the next year. Before you go to talk to the physician about alternate care settings, make sure you've done due diligence, and make sure you have an idea of what other setting might be more appropriate for this particular patient, and, you know, you want to just come with a recommendation in mind. And don't forget that your traditional Medicare patient does not need three-day qualifying inpatient stay to be admitted to a SNF during a public health emergency. I guess we're kind of over that now. But should you be in a public health emergency situation, you should just bear that in mind. Now patients coming in for surgery, being admitted the same morning of the surgery, you do want to allow your admitting or transfer center case manager to review them the day before, make sure they've gotten their pre-auth, make sure or begin to develop an appropriate discharge plan, particularly if they're ambulatory surgery. I had ambulatory surgery, as I think I mentioned last week, and nobody discussed with me what to do when I can't walk on my left leg, you know. Nobody talked to me about how to go to the bathroom, how to take a shower, nothing, nothing. And that, you know, is a huge problem. I knew what to do, but again, your average patient isn't going to know. So we want to make sure we're focusing on discharge planning for these patients as well. So this is another gap filler that these folks can provide. I think I talked about the pre-admission testing process and how the admitting case manager can also intervene in that process by perhaps discussing discharge options or other patient education information before the patient even comes into the hospital, thinking about, you know, some of your, let's say, hip replacements or what have you, they're pretty routine and you pretty well know what they're going to need post-op. And so even if they're ambulatory surgery, you know, they're going to need some discharge planning and how is that affected in your hospital? Who's going to order PT or remind the physician, I should say, to order PT? Who's going to get involved with those kinds of things? Otherwise, some of these patients can fall through the cracks. You want to coordinate and facilitate care on all of these patients. Outpatient in a bed, you know, these are patients who don't meet admission criteria, they don't meet observation criteria, but you're unable to send them out into the community immediately. So they're taking up a bed, but you don't want to put them in observation. You really should not. If they don't meet criteria for observation, they should not be in observation. And what you want to have is a registration code for outpatient in a bed because for lack of any other registration code, we see these patients being put in observation and then they're in observation for five days, you know, or even admitted. If they don't meet any criteria for either level of care, they should be considered an outpatient in a bed and you're not going to get reimbursed for them, but you're not going to get reimbursed for them anyway, and it doesn't skew any of your other data. So just something to bear in mind. And then we have another role called Transitions Case Manager. I like this one, too. This is another gap filler. These are your high-risk patients, high risk for what? High risk for not doing well in the community, high risk for returning to the ED, high risk for potentially being readmitted. So this is a telephonic position where this transition case manager follows these high-risk patients as they leave the hospital and she follows them telephonically. She may intervene if there's a community case manager, she would interact with that person and or the primary care provider or home care, anybody else that's involved in that patient's care. So she might look at frequent readmissions or specific diagnoses and particularly focusing on particular chronic conditions, frequent visitors to the ED or patients who are simply having difficulty managing independently in the community. Now this is telephonic and it's usually up to 30 days after discharge. However, it could be extended if necessary or shortened if necessary. The number of calls will again be dependent on the patient's needs and what the case manager thinks. But this is a way maybe to identify something that's starting to fail for that patient in terms of their post-discharge plan and the transition case manager can get in there quicker, identify the problem quicker and hopefully prevent that readmission. And then your transfer center case manager, again, if you want to combine it with admitting but if you do have just a transfer center case manager, they're really managing the transfers coming into the hospital and reviewing those as we said for medical necessity, both level of care as well as status. And so if they're owned, you know, acute hospital, acute rehab, LTAC or SNF, you know, these are the types of transfers that you really do want to take a hard look at. You want to have working rules of EMTALA understood for you as well as the ED case manager just so that everything is handled appropriately. You can be a liaison between the hospital sending the patient and the case managers on the unit regarding medical necessity. So if you've done that medical necessity review as the transfer center case manager, you're going to have that information handed off to the inpatient case manager. Authorization for any patients transferred in who are out of network, timely acceptance of patients being transferred in, and that's really important. You know, typically we see physicians, you know, just telling the sending hospital, okay, I'll take the patient without talking to anybody about it, you know, that's very problematic. So you want to make sure your physicians understand they have to go through this person. Working with patient access, you want to identify these non-EMTALA patients who are transferred in. You can review documents if you can, and if you've got patients waiting to transfer in, you want to really review their documentation on medical necessity and any potential discharge planning barriers. That's the other one, you know, like somebody sending a patient because they don't have a good discharge plan identified, and all of a sudden you get that patient. And then your transfers out, of course. Usually this is done by the staff on the unit, but in some cases maybe the transfer center case manager might be responsible for patients transferring out as well, and so needed paperwork or authorization can be managed by this person as well. Now another position I feel is absolutely necessary is an audit and appeals specialist. What do I mean by this? This is the person who's coordinating and facilitating the denial and appeal process. They are responsible for assisting when an external reviewer comes into the hospital. They serve as a resource to the case management staff. They maintain a database, and this is really important. They are the owner of the database. How many denials came in? What type of denials? What is, are we appealing it? What is the appeal status? Did we recover or lose on the appeal? You know, that kind of stuff that we will look at in webinar five. They are the ones that are going to maintain that particular database. They're going to generate reports based on that data, so their ability to catalog data and run reports is important to this particular role. So I think it's really a great role, it's a back office role, and again, maybe a promotional opportunity for somebody who has been in the case management role for a while. And it's a role that can be a leadership position as well. Then you have the perioperative case manager. Now this is a role that I would tell you to only consider if you have enough volume of surgical patients. So if you've got enough volume, you want to have this case manager responsible for that patient during the whole perioperative process, which is from pre-admission testing through to the recovery unit, the PACU. They're going to provide clinical coordination and transitional planning across that continuum, across that perioperative continuum. That's their scope of responsibility. They're going to look to remove any barriers to moving that patient through optimally, coordinating the discharge from the PACU. Now this is a person who can help on those ambulatory surgery patients, if they're going through your inpatient operating room and not at an ambulatory surgery center, well, you know, they can help with discharge issues, whether it's a direct referral for home health or DME or whatever it might be. And now my very favorite, the case management clerical support staff. Woo-hoo, right? Oh my gosh, how many of us spend half our time doing clerical work? I was alluding to this earlier. Let's look at what fabulous things this role can do for us. These are non-licensed professional staff. They are specially and highly trained in this role. So they need to be really educated in how to do this, first and foremost, if you're thinking about that. So many times they're handpicked. Every hospital I've gone into as a consultant where we have implemented this role and advertised this role, we got so many applicants and excellent applicants. So it is an appealing, it's an attractive role for many people. Now, unlike your clerical staff or admin staff in your case management offices, this is a role that works on the units and works directly with the RNs and social workers. So I kind of, you know, equated to a nurse aide, nursing assistant who's working directly with the staff nurse. These folks work directly with you. They report to you. They can carry caseloads typically of up to eight professionals at a time, and it can be a mix of RNs and social workers both. I broke out what they can do by category. So in terms of discharge planning, what I've listed here are all the things that we do not need a licensed professional to do, but that a trained person can do. So I don't want to read all of these to you, but you can certainly see some of the things that you may currently be doing that you don't need to be doing, whether it's making a packet, whether it's ordering, you know, getting DME, transportation ordering, physician appointments, you know, and so on and so forth. All that stuff. All that stuff. And maybe more, maybe less, depending on how you might want to do it, but oh my goodness, what an opportunity to allow you, again, to work at the top of your license. They can help with compliance. They can bring in the important message, and you might be saying, well, you know, what if the patient has questions? And again, this person is trained in what to say. CMS does not say it has to be an RN or a social worker. So they can bring in the IM. They can explain it. And then if there's questions above and beyond what they can respond to, well, sure, then the staff would come in. They can deliver the moon. Same thing. You know, they can bring in the RN and the social worker if there's too many questions. They can help the patient make their choice selection from their list. So lots of good stuff there. They can obtain authorizations from commercial insurance companies, as I just said. So not only are they going to call and get the ambulance, but they're going to get the off ahead of time. Even referrals to home care or medications, anything like that. They can fax or scan if necessary. I have to tell you, these positions are great. They aren't highly expensive. But they support you guys. And so if you have a combination of case management software and clerical support staff and all the right mix of specialty positions and the right staffing ratios, you've got a department that's going to work perfectly. I really mean that from the bottom of my heart. So I just wanted to say, build a case management system from the many roles that we've talked about today. Okay. I'm going to turn this back to my friend here, Lindsay, and see if we have any questions. Perfect. Thank you so much, Dr. Sesta. And before we do that, let me just remind everybody to go ahead and be typing in your questions here. I think there was one comment that says, not a question, but the handoffs with hospitalists are hard. It can also delay discharge even when everything is arranged. Yes, I agree 100%. And that comes down to, again, your hospitalist leadership. And that's a great opportunity to do a performance improvement project, particularly if it's happening with more than one of them. That's coming from the expectations of the leader of that group. Or maybe they're not even aware that it's a problem, but you need to sit down with them or somebody needs to sit down with them. And you have to figure out how pervasive the problem is and then see if everybody can work on it to try to fix it. The same thing happens with nursing. When they delay the paperwork for a discharge, if they don't know what that impact is, I mean, it seems common sensical to us sometimes. But if they don't really think about it or pay attention to it, then we have an obligation to bring it to their attention because it impacts on everything. So I thank you for that comment. Absolutely. Okay. I don't see any other pending questions here. So if you are typing one, as I said, that one just came in here. This says, so a non-licensed clerical staff member can submit a PA and clinical notes to insurance. Is that correct? Yes, absolutely. They're just submitting it. Yep, absolutely. You know, and if you honestly, if you have any question about whether or not that's acceptable in your hospital, you know, that's something you can bring to your legal department or your compliance department. But, you know, just you just have to think about it logically. You know, people in the admitting office are getting all kinds of paperwork like that and their clerical staff. So, you know, think about it in a similar fashion. Yeah. Perfect. Okay. So if you are typing any questions, go ahead and do that. Now, as we start to close out and looks like one other one just came in, this is for physician advisors. What have you seen works the best in-house grown or outsourced? Oh, in-house. Oh, I thought I made that kind of clear. Absolutely inpatient. Outsourced, if you go back to those couple of slides, outsourced creates a potpourri of problems, whether it's, you know, the physician not taking the call, the physician resenting being interrupted in the middle of the day, the physician not understanding what credibility that caller may have or not have, the timeliness of a response and ability to keep the data of the intervention of the outside group. And I could go on and on and on. So yes, yes, if you can get the right person who's an employee of the hospital and is physically present and when there is an issue, he or she can speak directly to that physician, maybe even on the unit. They can go on rounds. They can do all sorts of fabulous things. To me, that is best practice. Perfect. Okay. I think that was the last question that I see that has come in. So if anybody has any last minute questions, go ahead and be typing those into the Q&A option found there at the bottom of your Zoom window. Or if you don't see that, you can, of course, type that into the chat option as well. And then I did go ahead and just post some additional notes for you all. As a reminder, if you have not joined us for the first two sessions, then just note that you will receive an email tomorrow morning, but that will come from educationnoreply at zoom.us. And so because it does come from that Zoom email, it may get caught in your spam quarantine junk folder or something of that nature. So if you don't see that email in your inbox in the morning, I would encourage you to check those additional folders. And then if you still don't see that message and you'd like to access the recording of today's webinar, you can always use the same Zoom link that you used to join us for today's live presentation to also access the recording. And then just remember that the recording will be available for 60 days. And we do have that additional security measure in place to protect Dr. Sesta's intellectual property here. So you will need to click on that Zoom link, type in your information that will prompt an email to come to us for approval. We do approve those very quickly, typically within just a few moments of receiving the request. But then we ask for just one business day to formally approve all of those requests. And again, you'll have full access to the recording for 60 days from today's date. And also included in that email will be a link to the slides that were presented. But I did go ahead and provide that link there for you in the chat to have as a resource now as well. And then if you do have any additional questions at the conclusion of today's presentation, you can always reach out to us at education at gha.org. We'll be happy to work with Dr. Sesta to get those questions answered. OK, perfect. I don't see any other pending questions, Dr. Sesta. So as always, thank you so much for your time and information that you shared with us again today. We look forward to having you all back with us next week for part four. And I hope you all have a wonderful afternoon and a great weekend. Thank you, Dr. Sesta. Thank you so much. Bye-bye.

Dr. Toni Sesta

case management

physician advisors

hospitalists

collaboration

patient care

specialized positions

cost management

post-discharge clinics

transitional care

readmissions

interdisciplinary teamwork

effective communication

discharge planning specialists