kick off part five for us today. 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, to close out our series. We invite you to go ahead and get us started. Thank you so much, Lindsay. Good morning, everybody. Well, I can't believe it. We made it through module five. I'm just amazed. And I'd like to start off our last module by putting out my thanks to Lindsay Kaysen for all her support as we put these programs together, and she does a fabulous job. And Lindsay, I just want to personally thank you so much. There's a lot of work that goes on behind the scenes that people don't even realize. So thank you, thank you, thank you so much. Thank you. Yeah, and it's always sad when we end a series, but all things must come to an end, and I've probably stuffed a lot of information into everybody's brains over the last few weeks. So as Lindsay said, I'll just repeat, any questions you may have after, even after the series has ended, I'm happy to answer. So today what we're gonna do is bring together all the different things that we've talked about over the last several weeks, kind of into a pictorial of what this all would look like when it all pulls together. And I've got some forms, you know, there's some new things that have come out that warrant another look, for example, at your Social Drivers of Health tool. We'll talk about that, we'll talk about how, well, let me say a compliant case management assessment form or tool, I know these would be automated, but I'm gonna give you the paper version, how these would look. So we'll be getting into that, and I have a ton of slides yet again. So I'm gonna get us going, here we go. So let's start off, because today it's all about roles and models and functions and what everybody does and all of that. So when you think about the roles, and we've talked about some of our roles, we've talked about utilization management, we've talked about discharge planning and transitional planning, and we've talked about care coordination as our big three. Those are sort of the pillars that we sit on, and those are the big roles that we perform. So these are your key categories. So when you think about it in terms of your roles, it takes you out of sort of the tasky mindset that we so often fall into as case managers, where I just have to do this and this and this, and I'm not really thinking about how all of this integrates together. Now you may apply your role a little differently depending on where you are. So if you're in the ED versus an inpatient unit, if you're in the home care outpatient setting, if you're in an observation unit. So there are some different ways in which you would apply these larger roles. And so here's sort of the laundry list, and we've seen this before. So we have patient flow or coordination and facilitation of care. As I mentioned, utilization and resource management. Denial management, avoidable delay management, a lot of management. Discharge and transitional planning, even quality management. I'll touch on that today a little bit. And then the big new thing that CMS, Centers for Medicare and Medicaid Services, is focusing on now is psychosocial assessments and interventions, and they are hot onto this. They call it social drivers of health, so we'll talk about that. So then you've got these larger roles, and then you've got this series of tasks that you perform to carry out that role, and those are the functions. So those are more of the tasks. How do I perform discharge planning? Well, we went through lots of the processes and tasks that one has to perform to carry out the role of discharge planning, so I hope that makes a little bit of sense, because it's important to understand this as we look at models and how all of this fits together. So these are your actual, you know, you carry out action items that you perform. Now, the functions may vary from model to model, or how they're integrated or combined with each other may vary. So let's talk now about role number one, and this is not really in any particular order, but to me, I like to start with patient flow or coordination and facilitation of care, because as you'll see as I go through this, it's the foundation, in my opinion, and everything else sits on top of this. So that might not make sense right now, so just hold that thought. So how do we coordinate care? We talked about this, I think it was last week, if I'm not incorrect. How do we coordinate care? Well, we manage all the patient care processes that support our patient as they move through the continuum. So for us, our continuum would be from the emergency department to discharge, and even post-discharge. We have an obligation, when we talked about discharge planning, how CMS is now looking beyond just the walls of the hospital. Now they want you to be sure you've picked the right post-acute provider based on quality indicators. Your financial gain or loss may be affected by which provider or a bundle payment or any of those models where reimbursement carries through to the ambulatory setting. So it is really important that we define, depending on the patient, what that actual continuum is, and we don't always know. Sometimes we don't know a patient's in an ACO, for example. I'm hoping that will get better, of course, with time. So as we facilitate and coordinate, we're looking at tests, treatments, procedures, consultations, maybe a patient going to the operating room, maybe they're having a bedside procedure, anything like that, any interventions that need to be coordinated and facilitated. So patient flow and why I think it's so fundamental is that we are there to optimize each day that our patient is with us in the acute care setting and, to the extent possible, include evenings and weekends. We want to make sure that as we optimize each day and we coordinate those processes and interventions that we get them in the right sequence. And by facilitating them, we can hopefully reduce the delays that may happen and things get done in a more timely manner. If we're, you know, if somebody's on it, if somebody's looking at it, you know, we don't necessarily see our direct care providers with this kind of an approach. So it falls upon us as one of our core roles. So again, in order to facilitate and coordinate care, in order to affect patient flow, you have to assess every patient on admission. We're gonna talk about, and I'll show you a form. Reassess the patient every day, not with a form, but maybe with walking rounds or some other daily rounding conference rooms, not really rounding, but some kind of a modality where you're bringing the team together and then coming up with a plan. And as we like to say, the plan for the day and the plan for the stay. So once we have a plan, we can coordinate those interventions. If we don't have a plan, if we don't know what the expected length of stay is for the patient, really hard to be prospective in our coordination and facilitation functions. And this is why this conversation with the physician in particular has to start early. We also, again, wanna coordinate with our family and family caregivers, if there are any. And the other really key thing in my mind is identifying those delays in patient care processes and then intervening to correct them. So one, we identify perhaps a delay, but then we do something about it. By doing this, we have some goals that we're able to achieve. So we expedite the plan of care, we identify barriers that affect efficient throughput, and we correct them. Now, not all of them will be correctable, but there is a proportion of them that will be correctable with our intervention, leading to patient care being provided in a timely manner. And the patient having what I call a smooth move through the continuum, a pleasant experience, perhaps we might say, not an experience where three different physicians come in and tell the patient three different things, but where the team together is saying the same thing and working as a team. And then the byproduct of that is each day is optimized, which helps with reimbursement. Which brings us to role number two, which is utilization and resource management. So, utilization review. If some of you were around, I know I'm dating myself, but although I wasn't in case management in the mid-'80s, I did see, well, more toward the late-'80s, we saw a transition of what were utilization review nurses into hospital case managers, title only, really, because they just continued to do clinical reviews and sometimes send those to third-party payers. Now, at that point in time, we had much less managed care, and we had the conditions of participation, which called for reviews to be done for Medicare patients. So, I do remember in some of the early days of case management where utilization review was only being done on Medicare patients. Well, we wouldn't even think of that today, right? We think first of our commercial payers, but it kind of started the other way around. And then as we got more invested, ha-ha, in resource management, managing the dollars, we looked at the resources being ordered for the patient by the physician. One, that the appropriate level is applied, but also that we're not overdoing or underdoing. So, that piece of it led us to doing more reviews, making sure the care is medically necessary and reasonable. Remember, how do we know, how do you know that care is medically necessary and reasonable? You know that because you use a set of criteria that your hospital has purchased. And I'm not here to sell anyone, but Interqual is one, Millman Guidelines is another. There's others, but those are the two most common, certainly, that I see across the country. And by using those criteria sets that are based in research and evidence, that's how you determine that that patient's care is medically necessary and reasonable. And, of course, that it's in the most appropriate setting. So, medical necessity is really the key to utilization management. And then as I said, as case managers, we're also, it's almost impossible not to look at the resources being consumed at the same time that we're doing some of these other things. Is the physician over-ordering? Is the physician ordering things that have nothing to do with the patient's reason for being in the hospital? Or are tests being done redundantly for no reason? At least to have a conversation with the physician about that. And then under-utilization, that really gets back to the coordination and facilitation piece and knowing what the care plan is and seeing, geez, we didn't order this or that that the patient should have had by now, and then facilitating that. So, again, those direct care resources. If you remember, we talked about how cost is calculated. So, when we look at cost, we wanna see what services were provided directly to the patient, not the indirect costs, which are lighting and heat and insurance and things like that, but the resources consumed by one patient. Pharmaceuticals, radiology labs, and all the other stuff that patients receive. So, the goals here, then, are to ensure that the resources are used appropriately, that they are provided in a timely manner, and without unnecessary delay, and that will ensure reimbursement. Okay, number three. Now, you could put denial management under-utilization management. Some of these kind of fall together. Today, we'll split it out. We'll talk about it as a specific role. And it has two prongs, right? It has what you guys do on the units to prevent a denial, and then there's what we do on the back end. When we do get a denial, how do we appeal it? So, we have concurrent and retroactive appeals that we take into account. Probably you, if you're working on the unit, you're getting more involved with those concurrent denials than you are with the retros, but who knows? Everybody's model's a little bit different. So, what is denial management, then? It's the process of monitoring and managing third-party payer reimbursement. And the whole process starts from pre-admission, as we know, and goes to post-discharge. So, pre-offs, billing, and appeals. Now, you may have some appeals sitting in your finance office or under case management. You can have, excuse me, technical denials, which really don't apply to us because we really deal more with clinical denials. So, things do get split up sometimes. So, in denial management, how we reduce the likelihood of getting a denial, and I'm sorry to say, there's probably always gonna be denials. However, I wanna also say that we can mitigate the volume of denials to some extent. That's part of our responsibility as case managers. So, one is that the information in the medical record is accurate. I should add, timely, reflects the care being rendered, up to that moment in time, all that clinical information. Now, you may have a CDI person, clinical documentation improvement person, who's working on that as well, and that's great. And I love to see when hospitals have that because it really does help you get those higher-weighted DRGs. So, you may, however, notice something that the CDI person didn't pick up on, and you can certainly share that with them. You wanna make sure that you send your information to the third-party payer on time and using those nationally established guidelines that we've talked about. So, what can happen is if you don't send your review on time, if you have a cutoff time in your managed care contract, and you send it after that, well, that can be a technical denial. When they say technical or administrative denial, it simply means that you fell outside the rules in your managed care contract. So, let's just say your managed care contract calls for reviews to all be submitted by 1 p.m. And you don't do that, you're late, you're 1.30, well, that's just an excuse for them to give you a technical or administrative denial. So, when I talk about needing to see those managed care contracts for the case management department to see the UR portion of the managed care contract so you know if there are any expectations like that that you're not even aware of. So, that's why I kinda get on that bandwagon quite a bit because you can't comply with the rules if you don't know what the rules are. Okay, and then that the patient is transitioned to the next level of care as quickly as possible. So, once we know that they've met the outcomes that they're meeting and have completed the, well, the stuff in the clinical guideline that you're using, they can be transitioned to the next level. So, now you start to see where denial management, utilization management, and discharge planning interface with each other. You do wanna work closely with your pre-cert staff and those notifications can happen in your admitting office. You know, you're gonna get involved with some authorizations when it comes to discharge planning. So, there is some overlap between us and the front end, the folks at the front end, and then the billing staff at the back end. So, we're kind of in the middle most of the time between those two. And it's important to have a good working relationship with those folks. In your department, in your hospital, maybe your appeals are done by maybe some folks in maybe your finance area, for example, if it's those technical denials. Or in your case management department, if they're clinical denials or some combination thereof. Or you have outsourced your appeals to a company. And some folks have done that for the RAC denials, for example. But some hospitals certainly that I've worked with have outsourced all their appeals to an outside company to do. I like to keep them inside because I like to keep control over everything. That's my, I'm just giving you my personal opinion on that. But of course, you know, if you like football, a good defense, a good off, ooh, best defense is a good offense. So, we always wanna try to prevent denials. And as I said, there's always gonna be some. So, kind of the way of the world for us. All right, now, avoidable delay management, I have today as role number four. Well, sure, that can go under care coordination, so you start to see, again, these overlaps. So, avoidable delays, you may call them avoidable days or variances. Back in the day, I used to call them variances because they were a variation from the expectation. I don't like calling them avoidable days because sometimes it's only part of a day, and a lot of the current case management software allows us to put in hours. We don't have to put in a full day. So, you know, if it's an overnight delay, let's say, of the patient, you know, getting to the OR or something like that, you know, and it's 12 hours, you may be able to actually catalog it that way. So, these are the causes of delays that affect patient throughput or patient flow or the direct care delivery, as I just suggested, or even the patient's discharge. So, they may or may not actually result in a prolonged overall length of stay, but they identify a gap in care, a service delay, and maybe a quality of care issue. So, if the patient's not getting what they should be getting in a timely manner, well, to me, that's a quality of care issue. So, what are the functions within avoidable delay tracking? Identification of those delays, service delivery, or quality of care. So, again, you've got to know what that plan is. You've got to be looking at that every single day. Interventions to correct. So, again, not just identifying the delay, which was how you OR was done way back, but then doing something about it whenever you can. Calling the department where the delay is occurring and finding out what's going on, trying to facilitate it. Talking about the delay on patient care rounds so that the rest of the team knows what's delayed and why it's delayed because it may affect the plan of care if it's a long enough delay. And then, finally, putting it into a database for further analysis because you may find those patterns and trends that lead you to some improvements. So, let's just see how that goes. So, when I say putting it into a category, we have internal systems, systems outside the hospital, patient issues, so issues directly related to the patient or the family, provider issues and delays. And I think we talked about when we say provider, we mean physicians, physical therapists, staff nurses, anybody giving direct care at the bedside, and payer issues. And you could have more. You could have legal as another category, for example. So, it really depends on how you want to slice and dice your own data. And as you do that, you may find one important single event, but big enough to warrant further analysis, where you may see a lot of variation from established levels on something. And the big one for me is those patterns or trends that vary from expected outcomes. So, if you see a lot of delays over the weekend, as we've talked about, because of a CAT scan delay or an MRI delay or whatever, you know, if you see enough of those days adding up over the period of a month, well, gosh, you know, there's your opportunity for looking deep into it. Not you guys at the bedside, but certainly you leaders, you know, to look for an opportunity for improvement, working with that other department. And role number five, as we talked about, discharge planning, the movement of the patient through the acute care continuum and to the next level of care, the identification of that appropriate and safe next level of care. When we say safe, we don't mean the patient's going to go somewhere where they're going to get beat up, of course. We're talking about maybe an older person discharged to home and the home environment is just not safe. It's scatter rugs. There's, you know, the patient can't cook for themselves. You know, different things that make that level of care not safe for that patient. So a definition here that I wrote 100 years ago, a collaborative interdisciplinary process of assessment, planning, implementation, and evaluation of the patient's healthcare needs following the current phase of illness. So, of course, we assess the patient's needs that they will have after they leave the acute care setting. So that knee-jerk patient's going home has to be dovetailed with what that home is going to be like. And so we have to really take it to the next level. And we want to make sure that the discharge is timely and it's appropriate, it's incorporating the best use of resources that the patient may need in the community. So, again, let's remember that CMS wants us to look not just for the clinical needs of that patient post-discharge, but also to look at the non-clinical needs that that patient may have, meal delivery, maybe an adult day program, get the person out of their apartment or house, anything of that sort. And then quality management. So we don't have direct responsibility in case management for quality, but in my mind everybody on the interdisciplinary care team has some responsibility for ensuring that that patient is getting quality care. And what does that mean? That the care is rendered at or above quality standards. So we will certainly come upon some things. We may come upon an adverse event. When we get involved with readmissions, and I'm going to talk more about how you can integrate that into your tool, when we identify a 30-day readmission on admission, excuse me, and we look for the root causes, let's take a sip here, and we look for the root causes of that readmission, well that is a quality of care issue that we're involved with. And then managing the progression of the patient toward those outcomes of care is also a quality of care issue, because as we reduce gaps and delays, as I said, we are affecting quality in a positive way. So you probably don't have responsibility for the functions under quality management. I haven't seen a hospital try to combine quality and case management in quite a while. I don't think that's happening too much. But even if you don't have primary responsibility for quality, you're still a member in the quality of care process. You're still collaborating and identifying those issues, as should all the other team members. Okay. I thought it was really important to talk about this admission assessment tool that I have alluded to multiple times through the webinar series, because I do see in my travels around that not everybody's got a tool that meets all the CMS requirements under the conditions of participation for discharge planning. So I thought it would be helpful just to give you an example of what that should look like. Of course, you can put it in electronically with dropdowns, either in your case management software or your electronic medical record. Obviously, most of us are not using paper anymore, so that would be where it would go. Now, I'm going to call it a form, but I understand it's not. But it is a catalog of certain information. And as we've discussed, it should be completed on the day of admission or within the next business day. So if you know you have not great staffing on the weekend, make sure your own department policy allows for that gap in time if you're not going to get to every admission over the weekend. So sometimes the policy says within the next business day. When and how do we use this form? It's a readmission root cause assessment. It's your initial discharge planning evaluation. So it helps you identify the initial discharge destination right at the point of admission. Now, CMS says we have to just do it in a timely manner, but we know best practice. And, you know, we have an average national length of stay of 4.5, 4.6 days. We can't wait 24 hours. We have to start immediately. And then embedded in it, too, you can have referral to social work, if that's how you divide up the work, or even to home care. I like that, too. Again, it front loads everything, front loads it. It gets things started right away. The one I've created that we're going to look at gives you an opportunity to have your ongoing documentation of the discharge planning process embedded right in it. You can also certainly write free text notes. That's, you know, you can do that. But the tool itself really allows you to quickly and easily document the process. And it allows you to document the final discharge destination, the final discharge plan, transportation, and other completed tasks. That, again, if you remember when we talked about the discharge timeout, there's certain things that you want to be sure have been completed before that patient physically leaves the hospital. So this is another way to accomplish that. Okay. Now, I did as best I could to make this legible. It wasn't easy. But we're going to go through several pages or slides of what this looks like. So referral source, where did the patient come from? And why is that important? Because it may inform where the patient will be going and CMS's can the patient return to their prior living situation. You don't know if you don't know where they came from. Patient demographics, you can have those filled in automatically for the most part. Insurance information. And I'm not going to read all these, but you can see these bigger categories, which I probably should have put in bold. Referral source, patient demographics, and insurance information are important. Living arrangements, so where did the patient come from? If they came from home or they were homeless or lived in a shelter or in New York some apartment houses don't have elevators. You know, these are things that can affect the patient's, you know, ability to return home if they're having issues with ambulation. Are they on a bed hold from a nursing home? Things like that, as you can see. Their activities of daily living. Equipment that they might use in the home or have been using in the home. Support systems, again, CMS is looking at this. So are they using a service? Do they have a family caregiver? Now, here is your readmission risk assessment. Now, you can certainly add to this, but I have to tell you I've done some research and I've worked on some projects on identifying the causes, the big causes of readmissions. And so what I've got here for you are the big causes of readmissions. What I've got here for you are the big ticket items. That's not to say you're going to have a patient that falls outside of any of these. But, okay, so first and foremost was that the patient discharged in the last 30 days. Your IT system may be able to pre-populate that for you. If the answer is yes, what failed, the question really is what failed in the community that brought the patient back to the hospital? And then we have did not fill prescriptions, reasons. So the patient will tell you, I didn't have the money, I couldn't get to the pharmacy, whatever the issue might be. Did not take the medications as ordered with the reason. Did not have follow-up appointment with MD or primary care or specialty within two weeks of discharge. Did not have, and that contributed to their return to the hospital. Did not have means of transportation to appointments. Home care did not arrive. DME did not arrive. Pain not well managed at home. Did not follow prescribed diet. Missed physician appointment. Missed therapy appointment, and so forth. I mean, those are really your big ones. You can think of another one. You can certainly add it. But what this does is right on admission, you're looking for the root cause of that readmission to the extent that you can gather that information and then what? Well, I'm going to use that information to inform my discharge plan on. I'll show you that in a minute. And then if you have a model where you may be referring to your social worker, then I would say, and this, again, you can customize, and I think this goes on to the next page. So this list are the kind of things that you would want to make sure your social worker would be aware of. So a patient with any of the following discharge destinations in those brackets shouldn't be there. So as you look down this list, you're looking at shelters, domestic violence, assisted living, mental health transfer, psychosocial and other areas of support or not support. And so these are the kind of things, geez, it's a red flag to you, the nurse, filling out this form, and you're going to say, I need to get my social worker on this case. And as we go through the list even further, you can see, and some of these maybe aren't applicable to your particular hospital. This is a generic list. You can certainly add or delete from it. Now look toward the bottom here. Patient or family having difficulty understanding, accepting, or following through on the medical plan of care and continuing care options. Well, we know that happens a lot, right? So that's something we want to pull the social worker in on and any of these other things. So really what you're looking at here, very simply stated, is you're looking at psychosocial issues. These are not clinical issues. They impact on the patient's clinical care, clearly, but they're not clinical issues. So then we say patient meets social work referral criteria, which one or ones, and then they're referred. And then as I said, your home care referral criteria as well. I really like this. I've gotten a lot of positive feedback on this, and I just pulled some of the things. There's a lot more, as we saw in our district's planning webinar, a lot of home care referral criteria. I just pulled some of the ones I think that are most common, but you could add more to this, clearly. And remember, we talked about new medications or change in medications. We talked about IV injectables, obviously. And the one that I think is least understood or known is the very last one there, re-hospitalized within 60 days and or known history of repeated hospital readmissions. Well, there you go. So if you've got a patient that falls under that, Medicare patient, that would meet criteria. So does patient meet home care referral criteria, yes or no? And then do that referral right away. That doesn't mean the patient has to leave right away, but again, rather than waiting until the end of the stay. And then CMS wants us to discuss the patient's goals of care with the patient and family and incorporate that into the discharge plan. So here you can document what the patient's goals are, that you've discussed the plan with the patient and family, that they agree with it. If not, why not? And what your tentative discharge destination is at this point in time. And you've got the choices there. A choice list was provided to the patient and family, including applicable star ratings and quality measures. Hopefully you'll say yes to that. And you do not have to put the choice list in the medical record. I don't know how many times I've told folks this, so I'll say it again. But you have to indicate in your documentation that it was provided. So this meets CMS's expectation. Yes, it was. Availability of discharge services by type. Maybe your initial discharge plan was for the patient to go home with home care, and now you've found out they don't have coverage for home care. Does the patient have adequate financial support for safe discharge, yes or no? Additions or changes to the discharge plan related to the 30-day readmission clauses. So now I'm going to refer back to those clauses that I identified earlier. So let's say the patient didn't fill their prescriptions, the first one there. So what is my plan to address that so the patient doesn't get readmitted or come back to the ED again? So any of these that affected that patient's return to the hospital. It may have been an appropriate return. It may have been a legitimate exacerbation of their illness or deterioration of their illness. In that case, you know, none of these are really going to apply, although they could also be happening at the same time. So you really do want to dig in and then make sure it's part of your plan. And then transfers. EMS means a patient moving to a post-acute provider. They call that a transfer. Of course, we call it a discharge. But even if they're... Well, let me just say, if they're going to a post-acute provider, you have to be sure you're including the current course of illness and treatment, the goals of care, and particularly the patient's goals of care and the patient's treatment preferences. What equipment will they need? Are you using a vendor, and which one? Was discharge counseling provided? To whom was it provided? Mode of transportation for discharge and all the different choices there. If somebody's accompanying the patient, what is their name and telephone number? Was the transportation arranged, yes or no? And then the signature and name. So that sort of brings together a lot of disparate pieces that we have talked about over our series and pulls it into a tool. Now, as I said, you can certainly add free text notes if you feel the need to do so, and I'm sure you might. If you're doing patient education, you want to document that. If you've had a family meeting, you want to document that. So there's always going to be other things, but this is focused on the discharge planning process specifically. And then we have role number seven, psychosocial assessments and counseling. So, of course, we typically see these being performed by the social worker. They can be performed by the RN case manager, certainly in a pinch, but maybe not as well as our social workers. And then it may actually be more of a behavioral health or psychiatric issue, mental health issue that has to be followed through by your behavioral health team. Psychosocial interventions are really important, and I think they got short shrift for a number of years. I remember in the 90s, a lot of social workers were laid off. There was really a lack of appreciation and understanding of what social workers actually contribute to the interdisciplinary care team. I think that's starting to get better. And one of the best ways to do it is to make sure these social workers have a very clear and active role on the case management team. So we're going to look at some best practices for that. So psychosocial interventions, not just for the patient, but could be important for your family members, particularly if a patient comes into your ED or goes to the critical care unit or if you have a burn or trauma unit, your family members are going to be really stressed out. The psychosocial interventions have a direct relationship to discharge planning, how well that patient's going to do, what their quality of care is going to be, and, of course, with delays, it can affect utilization management as well. So psychosocial interventions are performed as part of your psychosocial assessment. You want to make sure you're assessing the family. In addition to the patient, I should say, the family, significant others, support systems. What support systems does this patient have? If a high-risk issue is identified, the case is referred to the social worker. The goals would be to identify your patient's ability to cope with their current phase of illness or their chronic condition. Is that impacting on the care they're receiving and or the discharge plan? It could be either one or both. So our social workers have a specific skill set. They perform biopsychosocial assessments and treatment planning. Counseling. And counseling can be on a number of... This is not therapy. It's counseling. It's providing support and guidance to a patient and family regarding the impact of their illness and maybe their compliance with medical or transitional plans. It involves crisis intervention, and it identifies barriers to affecting a safe and timely discharge plan. So their identification of some of these things or all of these things really are important to feed back into your discharge plan and your selected discharge destination. So your social worker collaborates with the RN case manager in the discharge planning process, but they're focusing on your psychosocially complex patients. So we do like to split it out by the nurse focusing on the clinically complex patients for discharge planning, the social worker focusing on the psychosocially complex patients in terms of discharge planning. And by doing that, then we're better assuring the patient's going to get access to the correct continuing care services that they're going to need. Okay. So CMS, I don't know, I'm going to say a year or two now, came out with the... They called it initially Social Determinants of Health, and now they've changed it to Social Drivers of Health. Now, I'm going to give you some of the things that they want you to tap in on, and then I'm going to show you a tool. The question becomes, when do you do the tool? Who does the tool? Obviously, the best group to do the tool is the social worker because these are social issues. The social worker may get referred the case soon after admission, or they can pick it up on their own. So CMS and the Joint Commission just list the things you see here, social support, disability, mental health, housing, transportation, all the things we have known for a very long time impact on quality of health. I've added adjustment to illness or difficulty coping, major illness causing a lifestyle change, behavior management problems, new or poor prognosis and stage of illness, family concerns or conflicts, cultural language issues, inadequate social or financial support, non-adherence issues, ethical concerns, abuse of any kind, or multi-system trauma, and even some more, psychiatric or substance abuse issues affecting the current hospitalization or the discharge destination. So if the patient has had a chronic psychiatric diagnosis and that chronic psychiatric diagnosis is not affecting the current hospitalization or the discharge destination, we don't need to pull the social worker in on that. Homelessness has gotten a little bit different because it's part of one of the social drivers of health. So we do have to go through that, and we'll go through that in a minute. Or a patient or family considering long-term care plans or hospice or assisted living or adult home. All of these are, again, psychosocially-oriented discharge plans. So the new rules regarding the social drivers of health, they're a little funky, but I'm going to go through them. So they want us to... Well, let me back up. Some of us have already started doing this, but 2025 is the mandatory reporting or data collection period. So screening for a social driver begins with voluntary reporting in the calendar year 2025, which, my gosh, you know, if you haven't started planning for this, you better hurry. It's getting close to it, followed by mandatory reporting beginning with the calendar year 2026. So in 2028, they're going to make payment determinations based on this information. So this is typically how they do it. They start with data collection that's voluntary, then they go to mandatory, and then they're going to start calculating reimbursement around some of the social drivers. So just very quickly, because all of you may not be involved in this, but I just wanted to let you know that this is going on, how social drivers will be calculated by CMS. So they're saying the numerator is all of your discharges who are 18 years or older on the date of admission and have been screened for the following reasons. And they have another acronym, health-related social needs, HRSNs, during their hospital inpatient stay. So the five they're initially looking at are food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. And then the denominator is simply the number of patients in the hospital who have been screened for the following reasons. And then the denominator is simply the number of patients admitted to the hospital who are 18 years or older on the date of admission. So this is just straight data. And then there are some exclusions for your patients. A patient can opt out of the screening. The patient is unable to complete the screening during their hospital stay or they expire. So the screen positive rate, I haven't really studied it yet, but some data just came out like in the last couple of weeks ago about with some of the screen positive rates or some of the data that's already been submitted. So again, begins with voluntary reporting in the calendar year 2025. Mandatory reporting begins in 2026. And we'll determine your rates in 2028, same thing. So the screen positive rate is a structural measure. It tells CMS the percent of patients who were admitted who are 18 years or older and were screened for these health-related social needs and screened for the following five, as we said, food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. Now, how do you get to a screen positive rate? Again, your numerator is the patients 18 years or older who were screened for all five of those that we've read twice. And the denominator is the number of patients admitted who were 18 and screened and were screened for all five of those. We're getting to your screen positive rate in a second. Okay. Now, what tool do you use to do all of this? It sounds complicated. You can automate it. Again, not something you guys have to worry about physically doing, but a tool you will need to be concerned with. So they've given us the choices of the AHC screening tool, Accountable Health Communities Health-Related Social Needs screening tool. That's a mouthful. The PROP-HAIR. Now, the PROP-HAIR is not new. It's been around for a while. Protocol for Responding and Assessing Patients' Assets, Risks, and Experience. And then there's other instruments that have been identified for Medicare Advantage Special Needs Population Health Risks Assessment. I don't recommend that one personally. PREPARE is a good one. I've used that one. I cannot speak directly to the first one. Or you can develop your own, and that's what I did, of course. So let's look at building one of your own, if you so choose to do. So we have the Family and Social Support section. Support systems. Does the patient have trouble taking care of a child, family member, or friend? Does the patient need help with activities of daily living? How often does anyone, including family or friends, physically help you as the patient? Disability status. Does the patient have a physical, mental, or emotional condition, such as difficulty concentrating, remembering, or making decisions? Because of a physical, mental, or emotional condition, does the patient have difficulty doing errands? Physical activity. In the last 30 days, other than activities related to work, how many days per week did the patient engage in moderate exercise? How many minutes did they spend, usually spent exercising at this level? On one of those days, how often do they feel lonely or isolated from those around them? Do they report that anybody is physically hurting them? What is their mental health history? Do they take psychiatric medications? In the last two weeks, has the patient, how often, rather, has the patient been bothered by any of the following problems? Little interest in doing things? Feeling down or depressed? Does the patient experience stress, defined as feeling tense, restless? So when you ask these questions, you can actually read off these. Do you feel restless? Do you feel nervous? Do you feel anxious? Housing. Where do they live, or are they homeless, or at risk for becoming homeless? Do they have trouble paying for air conditioning, heating, or electricity? That gets to a category that CMS was referring to. Has the electric gas, oil, or water company threatened to shut off services? Does the patient have trouble with any of the following? So pests, mold, lead paint or pipes, lack of heat or air conditioning, oven or stove not working. Smoke detectors missing or not working, water leaks. Safety. Because violence and abuse happens to a lot of people and affects their health, ask the following questions. Does anybody physically hurt you? How often do family or friends talk down to you? How often does anyone curse at you? Food. Does a patient report that the food they bought in the last 12 months just didn't last and they didn't have money to get more? Medication management. Do they have trouble paying for their medication? Do they have trouble getting transportation, medical appointments, meetings, work, or getting home supplies? Substance abuse. How many times in the last 12 months has the patient used any of the following products? Try to think of most of those. Do we have more? Yeah. Fentanyl, cocaine, methamphetamine, marijuana, alcohol. How many times has the patient used prescription drugs for recreational use in the past 12 months? Legal issues, religious affiliation, employment status, occupation. And they want you to ask if the patient is seeking a job. Is the patient interested in more education? Did you provide resources on that? Does the patient speak a language other than English at home? What is their income status? What are their positive characteristics or strengths? Sorry that got so big there, but what are their negative characteristics or concerns? Now, you may be thinking, as do I, what do we do with all this information? Oh, my goodness, what if the patient tests positive for something? Do I have to get them a home? What do I do? And we don't really know right now. I can't tell you because CMS is just asking us to collect this information. So from this, all of this can be pulled electronically to answer CMS's requirements. And then the other thing I just quickly wanted to mention are the Z codes. And as you remember way back, we talked about ICD-10 codes. Well, CMS has given us what they call Z codes. They go from Z55 to 65, and these are codes that are used to capture problems or risk factors that are related to socioeconomic or psychological circumstances that might affect the patient's health. Well, hello, that's what we just looked at. And they say, and this is the point I was trying to make, that data suggests that anywhere from 50% to 80% of health outcomes are attributed to social factors. I mean, think about that. All those questions we just went through, all that information we're collecting, brings us to potentially lots of issues that are affecting that patient's ability to be healthy or to achieve their health outcomes, whatever those might be. I mean, that's really huge. I think that really tells the story. So these standardized tools are going to help you in terms of the Z codes, but also be sure you're collecting the appropriate information and that it's integrated into your risk scores, eventually your reimbursement and value-based models. That's what we're going to see. Some Z codes. So why do we care about the Z codes? Well, we care because if your coders code any of these Z codes, it could move one of your DRGs from a non-CC, a non-complications or comorbidities, to with complications or comorbidities. So they're allowing psychosocial issues to be considered a complication or comorbidity. If you remember back to Module 1, when we bump from a non-CC DRG to a CC DRG, that means that we get more money. Now, that's nice, but it's also helping us to help the patient at the same time. So it's really a win-win. So in the Z codes, they're looking at homelessness, sheltered homelessness, and unsheltered homelessness. So if you've got any of those documented in the record, that may bump you up. Now, interestingly enough, we're still only reporting a small percentage of these. So this was from CMS Data Highlight. Now, it is from 2021. Granted, it's not current. Among the 33 million continuously enrolled Medicare fee-for-service beneficiaries in 2019, only 1.59% had claims with Z codes, but that was up from 1.31% in 2016. So I think we're leaving money on the table yet again because we're not documenting any of the Z code data that allows the coder to use it to up the DRG. So the five most utilized Z codes of the 10, homelessness, disappearance or death of a family member, problems related to living alone, problems related to living in a residential institution, and problems in relationship with partner or spouse, which is so interesting, and other than homelessness, not among the things I think that CMS had initially and currently is highlighting. So I just thought that was very interesting, so it really does help to document all this stuff for all the right reasons, so just wanted to let you in on that. Okay, so let's move on now to implementing the roles of the RN case manager and our social worker. Integration is the key. Now, I had somebody tell me one time when I gave this lecture and I talked about integration, they thought it meant that all the nurses and social workers should all just be doing the same thing. That is not what I mean at all, quite the opposite, because we know that our social workers and our nurse case managers have different but complementary skill sets. So we bring to the interdisciplinary team different knowledge, but it's complementary, so there's overlap, and that's okay. We overlap with all of the team members. How do we optimize those skill sets? That's really the question. So the way I visualize how we optimize the skill sets of each discipline in our model is to think about the discharge destinations that have more of a clinical bent versus the discharge destinations that have more of a psychosocial bent and give the discharge planning that is clinical to the nurse case manager and the discharge planning that is psychosocial to the social worker. So let's just look at some examples of what I mean by that, and there's many, many, many more, but on the left side, we have the clinical destinations, if you will. So home care, and it could be home care with an IV, oxygen, wound management, DME, acute rehab, subacute rehab, or short-stay rehab, whatever you call it, or subacute medical could be another one. So those are more clinically focused. We put those with the nurse. Psychosocial, hospice, home, inpatient, whatever level. Long-term care, SNF placement, outpatient mental health, acute psychiatry, and we could just probably put all of those social drivers there. In fact, I think I'm going to add those as another example because, frankly, you know, those may be the, you know, the impact that's so important, or on those, the collaboration will be important. And then access point case management. I also wanted to just introduce this to you. Access point, and by that we mean any of your routes of entry for your patients, and the goal is to manage and control the types of patients that are approved for admission. So we started with our utilization management talking about the two midnight rules, for example. Well, you have to begin that assessment process right from the point at which the patient enters the hospital, and there's lots of different ways that patients enter the hospital. There may be occasions where you can provide for alternative care when needed and appropriate at that access point, and by doing that, you're going to better ensure hospital reimbursement. So one access point job, if you will, is admitting or transfer department case management. Now this, if you're going to have a specific person doing this, you have to be a fairly large hospital. Nationally, 50%, again, this is an aggregate number, 50% of admissions come in through the ED, and another 50% come in other ways, like planned admission, urgent, direct, or transfer. Okay, so gatekeeping in the ED, but all these other patients are coming in, maybe 50% through these other modalities, and nobody's at the gate, nobody's watching, they just come in. So that's why we recommend having somebody who covers either all admitting and transfers. You can have, if you have a case manager in your transfer department, which I hardly ever see, but you should, then they can also do these other planned, urgent, and direct admissions, but again, you got to cover all your routes of entry. And of course, the emergency department case manager, gatekeeping, coordinating and facilitating care, utilization and resource management, and discharge and transitional planning can all begin right in the ED. So let me just say that that's also a super-duper important thing, just like it is in the admitting or transfer department, maybe even more so, but what you want to really do is do your first review of the patient, and or once the physician is considering admission and considering a specific level of care, that you're really taking a good look at that. He says, observation, you do your review and you say, no, no, this could be an admission or vice versa, and that's where your conversation will take place because you really do want to get that patient in the right level of care, you know, as I said right from the beginning, and that requires a conversation with the physician if you don't agree and you want to see if maybe there's more information to be gathered or maybe the physician, you know, just doesn't understand or made a poor choice. Any of those things can obviously happen, and so we want to get the patient in the right level of care right away. Okay. So I guess what I'm saying is you really can't have a best practice model today without gatekeeping all your routes of entry, and you can quote me on that. All right, I'm taking another sip. Okay. Another specialty position that I oftentimes recommend, and this really, again, would depend on how big your hospital is. I think if you're anything bigger than a critical access hospital, you would probably have an opportunity to need this position. Complex discharge planning specialist. Lots of titles for this job. I've seen many, many different titles, but what is this? This is typically a social worker who is going to pull out from all the patients those patients with the most complex, time-consuming discharge plans or patients exceeding your self-selected long-stay threshold, whatever that might be. So you may say anything over 5 days, 7 days, 10 days, depending on your hospital. And what this does is, by pulling out those time-consuming patients and giving them to the discharge planning specialist, it allows the staff, the RNs and social workers, to move the other patients through more quickly and not get bogged down with one patient. That could take a day, and we've all been there and done that. So this really helps move all the patients, not just these patients. If your position is filled with a social worker, they do have to work in conjunction with the RN case manager because the RN is the one doing the clinical review and such. So you want to make sure they are collaborating. And, you know, they may be interfacing with community and agencies, legal or police or community liaisons or what have you. So this is a very specialized position. Every time I filled it, either as a director myself or as a consultant, we really get talented social workers who take these really difficult discharge plans and become really adept at moving those patients. So it's something I highly recommend if you're a big enough hospital. Okay, let's look at a couple of models now. We've looked at our roles in great detail. We've looked at our specialty positions, and now we have to kind of pull this all together. So you can have the integrated model or the collaborative model. We're going to talk about both of those. Or some kind of a hybrid or a homegrown or something else. Now, I do not recommend a hybrid or a homegrown model. Why do I say that? I say that because we've had 30 years now of, well, maybe not, yeah, 30 years of testing out the integrated and collaborative model. And so rather than starting from scratch where you don't know if it's going to really work, you really want to embrace one of the best-practice models that's out there. Now, you may have to tweak it a little, and I get that. I'm going to give you best practice, and as always, I'll say that you may have to tweak it a little bit, but at least you're starting with a baseline model that's been tried and tested and works. Before you select your model, you want to make sure you understand your roles and functions and who's going to do what. That does fit into a model. So what is a model? So, you know, I've had clients say, I want to go to X hospital and see their case management model. Of course, you can't see the case management model. What you can do is have a conversation about the case management model, but you can't see it. So when we create a model, it's a description that helps us visualize something that we can't directly see. So it could be also considered an exemplar, an example, or an ideal. Today, it's definitely an ideal, what I'm going to show you. So you do need some of the specialized roles that I've talked about, and it really so much depends on the size of your hospital, where patients are coming from, and things like that, as we discussed. You also must, must have a clear demarcation of who does what. I can't stress that enough. Honestly, I can't. You know, I think I gave you the example of a hospital I worked with where, in the morning, the nurses and social workers sat down at a table and threw a bunch of admissions on the table, and everybody scrambled and grabbed one. That does not optimize the skill sets of each discipline. So that really is not the best way to go about this. But we also want to be unit-based, so we'll talk about that. Optimization of existing resources in your department. You know, how do you do the work optimally with what you've got? So you really do want to pick the right model for your organization, the one that you think is going to fit the best, the one that you think you can afford the best, and things like that. So we're going to look at the two that I mentioned. The first one we're going to talk about is the integrated model. This was originally called the dyad model. I framed the dyad model. Back in the late 80s, I came up with the dyad model. Now, back then, it was the RN case manager and the social worker, that was the dyad. But as you just saw, we've added so many more things, so many more specialty positions, and we've gone outside of just our roles, and we have a larger team. So we call it the integrated model now. We call it integrated because all the roles and functions are performed by that single case manager, and it pulls together what were previously disconnected roles. In the integrated model, as we just saw pictorially, is that a word? I think so. Discharge planning is assigned to either the RN or the social worker, depending on the patient discharge destination and needs. So we have the same set of roles, as we saw earlier, that are all part of the integrated model. So nothing new there. But let's start to look at how each discipline fits into this. So there are RN case manager in the integrated model. We have coordination and facilitation of care, utilization and resource management, transitional planning, discharge planning, clinically focused, variance or avoidable delay tracking, and quality management, such as we talked about. And then we have our social worker collaborating in the discharge planning, focusing on the patients with psychosocial destinations and doing psychosocial assessments and interventions. So by having the social worker principally focused on psychosocially-oriented discharge plans, what that does is free the social worker up to do psychosocial assessments and interventions. And what I so often hear is that they just don't have time to do that if they're doing 100 percent of the discharge planning in the hospital. They never, as much as they want to, and they know it's needed, they don't have the time to get to those assessments and interventions and counseling and all the things I mentioned earlier. So we're intentionally trying to take something away from the social worker, the clinical discharge planning, and free them up to do the psychosocial interventions that we know our patients need. And then we have our discharge planning specialist, part of our new integrated model. And we have the unit staff, let's say, the staff nurse, the nurse leader, the physician, and the physician advisor. You could add others there. You might want to add a physical therapist, for example, because we do interface and collaborate and overlap to some extent with them as well. And not to forget our community providers. So they're really part of the patient's team, be it subacute or home care or a community-based physician, particularly patients going home, that we get some kind of a handoff to the patient's community physician, be it a primary care physician or specialist, because we oftentimes neglect to do that, and so there's a big gap, again, in care. So this is kind of what it looks like. I call these my bubbles. They're not particular colors for any reason. I'm not very good at making these things, but you can see how they kind of all fit together. And then the number one question I get asked is, what are the staffing ratios? And I say, well, we're going to have to look at the staffing Well, it's going to depend on the roles and functions you've selected, the model you've selected, the hours and days your department operates. Do you operate seven days a week, five days a week, six days a week? Do your ED case managers work 12-hour shifts? You know, there's lots of variation. What are the size of your nursing units or size of your hospital, for that matter? And what high-risk social work criteria do you have? And what high-risk social work criteria are you using? So in the integrated model, let's look at a definition of an RN case manager's caseload. It could be, I'm going to show you all the iterations, but right now let's talk about a typical medical or surgical unit. The case manager is assigned 15 fixed beds that are her beds consistently every day. So this business of floating people around to a different place every day reduces continuity. It adds time and increases stress. It's not the right way to go. So you want to be staffed so that you can actually do that, have somebody with fixed beds every day. Now, we do know that patients are going to be discharged from those beds or new admissions received into those beds over the course of a day, so it's beds, not patients, because it may be more than 15 patients over the course of that person's day of work. But just to give you the variation in the ratio, case manager-to-bed ratio, you really do want to consider the clinical area. So for medicine, including medical subspecialties like oncology or cardiology, it's 1 to 15, neurology, 1 to 15, general surgery and surgical subspecialties, neurosurgery, orthopedics, 1 to 15, intensive care, 1 to 20. Now, you might be saying, why is that? Well, we typically have a bit longer length of stay there, and yes, we can begin discharge planning, and we should, but it's likely the patient is then going to go to a floor, maybe a step-down, and so 1 to 20 seems to work out well. So a step-down or an intermediate care unit, whatever you guys call it, 1 to 15. Peds, if you're not, like, a highly specialized pediatric hospital, you can go 1 to 20. Otherwise, 1 to 15. OB-GYN, same thing, typically 1 to 20, unless you've got a pre-partum. Antipartum, excuse me, couldn't think of the word. Antipartum unit with high-risk patients, then you might want to go to 1 to 15. Acute rehab, 1 to 15, and I really want to point out observation, 1 to 12, and you're probably going, whoa. Well, think about how quickly you want to facilitate and coordinate care for an observation patient. If we want to have our benchmark length of stay for observation to be 24 hours, the only way we're going to get that routinely is by really fast-tracking these observation patients. So that's why we recommend a 1 to 12 ratio there. If you go high on the ratio in observation, you're not going to manage your length of stay. It's just obvious. Okay, definition of a social worker caseload. It's a little different because, remember, the social workers are working off high-risk referral criteria. They're going to be assigned up to 17 patients. That's the cap. But these 17 patients may be located across more than one unit, depending on the size of the units, and about 30% of all your inpatients will match the high-risk social worker referral criteria, and of these, 17 will be assigned to each social worker. So in the integrated model, about 30% of your patients are going to have both the social worker and the nurse case manager working on that case together. Now, because the social worker is working only cases that meet high-risk criteria, well, a patient can meet that high-risk criteria on any unit. It doesn't matter because it's social. They're social issues. So we give them a 1 to 17 everywhere because you're going to pluck out those psychosocially intense patients. The integrated model process looks like this. It's designed so that all the patients are followed by an RN case manager. Every patient is assigned to an RN case manager. The RN case manager completes that assessment that we talked about, which has embedded in it, hopefully, your referral to the social worker or home care as needed. Patients are then referred to the social worker based on the high-risk criteria discussed. Patients are referred to home care as needed. The RN case manager follows the patient from admission to discharge and beyond, right? So they're admitting the patient and they're following them through the entire stay. The social worker completes the psychosocial assessment, the social determinants, health, drivers, excuse me, and they follow the case as needed. If they need only one intervention for that patient and there's nothing further, well, then they can close the case based on their professional judgment. So that's your integrated model. I also want to talk about the collaborative practice model. Originally, this one was called the TRIAD model, so you may have heard of the TRIAD model. It came out of Vanderbilt University Hospital. However, in the initial TRIAD model, the TRIAD was a case manager, I'm sorry, it was a clinical nurse specialist as the case manager, a social worker, and a business associate. So we've kind of changed that up. I doubt most of you use clinical nurse specialists as case managers, but it was pretty cool. What the collaborative model does is separate out the clinical work from the business work, if you will, of case management, and that is the fundamental difference between the two. We'll look at what that looks like. So we have three folks on the case. We have the case manager, the social worker, and the RN business specialist, or whatever title you want to put to that person. Usually it's Utilization Review, UM, for that title. The case manager does the risk screening, assessing and planning, same stuff, coordination of care, resource utilization, and outcomes management. The RN business specialist, now initially the reason they called it a business specialist was because they were, as I said, they were doing the business side of case management, but they were doing utilization management, and then they were also doing documentation review. Now, this was a number of years ago. I don't think there's enough time for them to do both, so I prefer to see CDI doing the documentation review. Of course, when you do utilization management, you're picking up on documentation issues, of course, at the same time, but it's not your primary responsibility. Now, the social worker in the collaborative model and the integrated model are doing essentially the same thing, so that is one of the consistencies between the two models, so allowing the social worker to focus on core social work issues, like I said, allow them to work at the top of their license, assisting with discharge planning for selected patients, those with the greatest psychosocial needs, and having clear criteria for referrals to social work. The staffing ratios in the collaborative model are a little bit different because you've got a third party, if you will, involved, whereas before, we were splitting up the work between the nurse case manager and the social work case manager. In this model, we've got a third person, so the staffing changes, so for the RN case manager, it's 15 to 23 beds, the RN business specialist, 20 to 40 beds, and the social worker stays exactly the same in this model, 17 patients, and following about 30 percent of the patients as active cases. How many staff will you need in the collaborative model? Well, the RN case manager also gets assigned 15 sixth beds every day, so that is the same. The social worker is assigned up to 17 patients, again, based on your high-risk referral criteria, these patients, depending on the size of your nursing unit, may follow patients over across more than one unit, and approximately 30 percent will match the high-risk social work referral criteria, so that's all the same. The addition, again, is this business specialist with 20 to 30 sixth beds per day, and we know that works. Okay. The process for the collaborative model, patients are assessed by an RN case manager. Now, here's where we get into a little bit of redundancy. They're also assessed by the business associate, so the RN case manager is doing her assessment, the business associate is doing their assessment in order to complete the clinical review. Both the RN case manager and the business associate are following the case. The RN case manager coordinates the care, completes some discharge planning functions. The business associate completes clinical reviews. The social worker completes some discharge planning functions and does the psychosocial intervention. So, clearly, you can see, because people get very confused about this, I want to really focus in on the fact that the fundamental difference between these two models is simply whether or not you've got a third person on the case management team who is pulling out the utilization management functions and strictly doing those. That is your difference, which means staffing is a little different. What people are doing is a little bit different. So, if you're confused about the two, this is it. I am not here to tell you one is better than the other. That's something you'll have to decide for yourself whether or not you want to integrate or separate utilization management. There are some advantages to each model, and you have to really weigh your pros and cons, so in the integrated model, everything is under one umbrella. You have that one person doing all the roles. Of course, that affects your staffing ratios, but everything is under one umbrella, which reduces duplication, fragmentation, and redundancy. However, on the collaborative model side, you've got the business side of case management under a different person, under one role, so that the case managers aren't consumed with routine payer functions, and I think that's one reason why people separate it out. The other reason I see people separate it out is they think it's less expensive. It's not. I've costed out both models. It's kind of a wash, you know, more or less, depending on how many specialty positions you have and stuff like that, but just looking at the raw three versus two doesn't change a whole lot from a financial perspective, so if you are leaning toward the collaborative model, do an analysis, you leaders, of whether or not you think that that's going to gain you any dollars on your budget, because it probably isn't going to. Other advantages on the integrated model side, data is collected once for multiple purposes, so our RN case manager does that initial admission assessment, uses all that information she's collected to do a clinical review. She's in the case, she's at the bedside, she's talking to the team, and she's got all the information to speak to vendors and third-party payers from a point of knowledge of that patient. On the collaborative model side, however, because you've split it out, the RN case manager has more time to focus on more leveraged functions and have an expanded focus on documentation. On the integrated model side, one-stop shopping. Anybody on the team knows this is the person I go to with any and all case management questions. May even be a little more cost-effective than the collaborative model because everything is integrated. Physicians and other staff members only have to communicate with one person on all issues, which makes it much easier. On the collaborative model side, you've got two very highly dependent, I'm dependent I should say, functions separated out, so you're separating utilization management from discharge planning. Decreasing the competing priorities between the two, you know, trying to get everything done in the morning kind of thing. Creates holistic jobs that optimize skills and talents of the different disciplines. How are they alike? Well, they build on the interrelationship of disciplines to enhance case management outcomes. So, in either model, that's really what they're looking for. But both models require strong social work involvement. Again, no difference there. To be successful, doesn't matter what model, doesn't matter what discipline. Every department and every discipline in the hospital has to have adequate staffing or they don't function well. And it's no different for case management. We have to have adequate staffing, a balanced workload, skilled staff, and strong leadership. To me, those are the four things. If you don't have all four of these, you have a problem. It's just not going to work as well. Now, as your workload goes up, your caseload has to go down. So, the more things you give the person to do, the lower the caseload should theoretically be and the more staff there should be. And we've talked a little bit about case management as an across-the-continuum model, but we have handoffs. So, as far as the acute care setting, as far as your hospital case management department is concerned, if you do have community case management, maybe in your clinics or your patient-centered medical home, you want to have one leader, one maybe vice president or a similar title to whom the director of inpatient case management and the director of community case management both report to. And that really helps to bring the inpatient and the outpatient settings together. For inpatient, each episode is just that. It's an episode of care. It has a beginning and an end, whereas patients in the community are going to be followed across their lifespan as long as they meet high-risk criteria. So, again, quite a bit different focus. As patients transition across the continuum, like we've talked about, you want to make sure you've got good handoffs. And it's really easy, much easier, when you're handing off your patient to another case manager if there is one. And then you're creating one single database for all your patients, regardless of whether they're inpatient or outpatient. And my goodness, look at this. Wow. We have finished. Lindsay, are you still out there somewhere? I'm here. I'm here. We made it. Oh, my God. You're still there. We did it with time to spare. All right. Oh, my gosh. Those social drivers of health are going to be the death of me, let me tell you. It is so complicated. It is. It's gotten so, so complicated. So, wow. We so appreciate you sharing all of that information with everybody. I do see one question has come in to the Q&A here. Okay. So, I'll read that off and we can go through that. But as I mentioned, whenever we first started, there's been so much information that Dr. Sesta has shared with you all throughout this five-part series. So, if you've been holding on to a question or just maybe something that applies to your organization, I'm sure if it's a question for you, others have that question as well. So, don't hesitate to type your question into the Q&A option there at the bottom of your Zoom window. Or if for some reason you don't see that option, you can, of course, utilize the chat, type your question there so we can make sure that we go over any questions that you have before we conclude this series today. Okay. So, this question, Dr. Sesta says, our case management department has now been placed on total patient days, hospital organization metric set by the consultant group, which now causes us... Oh, God. Those consultants. Oh, my God. It says, which now causes us to flex case managers off. Metric includes IP and observation, but does not include newborns. It also runs off of bed charges, which does not include discharges. How would you defend this process as not working, continuity, missed processes, et cetera? Wow. You know, I did stumble on this issue once before, and we talked our way out of it. Well, they were considering doing it. Flexing case managers off really makes me scared. Running off bed charges, which does not include discharges. You know, I see the person is anonymous. I don't know if that was intentional, but I would need to ask you a few more questions, and this is a very specific issue. If this person would be willing to email me and give me a little more detail when you flex off staff, because, you know, it doesn't really work. I even see critical access hospitals that will hold staff on days they don't even need them. I have to tell you, in case management, there's always a need. If you're going off these hardwired metrics and, you know, things change. Like you're saying, discharges really are our driver, but so are clinical reviews. And, you know, to me, it doesn't make sense. And what are we doing in the ED? There's a lot of questions I have. So I'm hoping this person maybe will reach out to me, and we can dialogue a little bit by email on it and teach me how you came to this point. I'm wondering if you're able to defend not doing it anymore or if it's a done deal. So, yeah, you know, maybe a done deal. I do not know. So let's talk. Thank you. Thank you, anonymous attendee. Absolutely. And I know that there may be several other, you know, very detailed situations like that that apply to your organization that you may feel more comfortable speaking with Dr. Sesta afterwards. So please don't hesitate to reach out to her. And you can always send any questions to us at education at gha.org. And we're happy to also get those questions over to her as well. We'll see. If we do not address the issues identified by the questionnaire, does that set us up for litigation, knowing there is an issue but not addressing the issues or all the issues? Not litigation, but if you're audited by CMS or the Joint Commission, they may very well look at that and give you a penalty on that. So that's more to the point. I mean, it's always been the case if you don't do a comprehensive assessment and the patient has a bad outcome when they leave the hospital because we didn't have the right discharge plan, that is sometimes looked at by your state auditors. But litigation, I mean, probably not unless a patient or family felt that, you know, we did something that caused harm to the patient. But you're at risk on other levels, you know, definitely. So because it's the conditions of participation, you really have to be compliant, as we've talked about. Perfect. Okay. If you don't see any other pending questions, Dr. Sesta, I'm going to put just some follow-up information there for you in the chat. If you've joined us for all of the sessions prior, you, I hope, are familiar with this process. But you should all receive an email tomorrow morning. And just note that it does come from that educationnoreplyatzoom.us email. And those emails do very often seem to get caught up in your spam, quarantine, junk folders. So if you just don't see it in your inbox in the morning, I would encourage you just to go check those additional folders first. And then if it's still not there and you would just like to access the recording of today's session, we do record these as on-demand, meaning that you can use that same Zoom link that you used to join the live presentation to also access the recording. Just remember that the recording link is available for 60 days from today's date. And now we do have an additional security measure in place so that we can protect Dr. Sesta's intellectual property here. So when you click on that Zoom link, you will need to enter your information. And that will prompt an email to come to us for approval of that recording access request. And then just give us one business day to grant those approvals. But we do typically approve those very quickly, honestly, within a few moments of receiving that email. Okay. I thought I saw a question come in here, but I did not. So great. And then also included in that email will be a link to the slides. 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're joining us, especially as a member of the Georgia Hospital Association, please do pay special attention to that email tomorrow morning. The link to the survey will be included in that email. And so you'll need to complete that survey in order to obtain your continuing education credit information and receive your certificate of attendance for the series. And if you're joining us as a member of a partner state hospital association, I do encourage you to reach out to your contact within your association so you can obtain any information regarding CEs that they are offering for you as well. As GHA is only able to offer CEs for GHA members. And again, if we can help answer any questions regarding this series, please don't hesitate to reach out to us at education at GHA.org. I know, Dr. Sesto, you've received questions throughout the series, and we just so appreciate you for always going above and beyond and answering those questions in a timely and thorough manner. I have enjoyed this series. I always love working with you, and just thank you so much for your time and information that you shared with our members and all of our partners across the country. And thank you all for joining us for this series. And, Dr. Sesto, I hope you have a wonderful week. And thank you to our attendees. Thank you so much. Thank you so much. And happy Halloween, everybody. Happy Halloween. Have a wonderful day. Thank you so much. You too. Thank you. Bye-bye. Thank you again. Bye.

Dr. Toni Sesta

Case Management Concepts

hospital case management

patient flow

resource management

discharge planning

RNs and social workers

psychosocial assessments

CMS guidelines

Social Drivers of Health

Z codes

reimbursement

integrated case management

collaborative case management