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By: Stephanie Jackson  |  Type: Article  |  On: October 27, 2017

CMS’ Discharge Planning Proposed Rule and the IMPACT on Post-Acute Care Transitions

The IMPACT Act, which is still in the process of being implemented today, was an effort to standardize those assessments across all PAC providers, so that case managers and others would be able to compare apples to apples and make the best care decisions for their patients.

No one knows better than a case manager the importance of quality data to help facilitate a safe transition of care for our patients. Quality data includes accurate, relevant and current information about the patient AND the post-acute care entities. In September 2014, Congress passed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. At the time, patient assessment data was standardized by provider type, but not across the different post-acute care (PAC) settings. So, a skilled nursing facility, a physical rehabilitation center, and other types of PAC facilities might have completely different sets of questions they asked during patient assessments, and different ways of recording that information. The IMPACT Act, which is still in the process of being implemented today, was an effort to standardize those assessments across all PAC providers, so that case managers and others would be able to compare apples to apples and make the best care decisions for their patients.

“In essence, the act seeks to standardize data elements used through various patient and resident assessment instruments by aligning certain data elements across instruments, to support our ability to measure and compare quality across the providers and settings of care,” said Patrick Conway, MD, MSc., CMS Acting Principal Deputy Administrator, and Deputy Administrator for Innovation and Quality, and CMS Chief Medical Officer, in a 2016 video from MLN Connects published on YouTube.1 “The act allows interoperability, which permits the seamless exchange of information across providers—not only PAC providers, but other providers who offer care to individuals as well. In the ideal state, important information would follow the patient, as services are delivered in hospitals and by physicians, long-term and PAC providers, and home- and community-based service providers. This will be a critical step towards coordinating care and proving Medicare beneficiary outcomes.” 

Certainly, the goals Conway mentioned are the same goals of case managers everywhere—to have a uniform way to measure and compare PAC providers in order to make the best possible decision for each patient based on his or her individual needs. But we’ve still got a ways to go.

In October 2015, just over a year after the introduction of the IMPACT act, CMS announced the Discharge Planning Proposed Rule, which would “revise the discharge planning requirements that hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals, and home health agencies, must meet in order to participate in the Medicare and Medicaid programs,” according to CMS’ website.2 “The proposed changes would modernize the discharge planning requirements by: bringing them into closer alignment with current practice; helping to improve patient quality of care and outcomes; and reducing avoidable complications, adverse events, and readmissions.” Importantly, CMS says, the proposed rule would also, finally, “implement the discharge planning requirements” of the IMPACT Act.

Under the proposed rule, hospitals and critical access hospitals would be required to:

  • Develop a discharge plan within 24 hours of admission or registration;
  • Provide discharge instructions to patients who are discharged home (proposed for hospitals and critical access hospitals only);
  • Have a medication reconciliation process with the goal of improving patient safety by enhancing medication management (proposed for hospitals and critical access hospitals only);
  • For patients who are transferred to another facility, send specific medical information to the receiving facility; and
  • Establish a post-discharge follow-up process (proposed for hospitals and critical access hospitals only).

With already-heavy workloads, case managers are going to need sophisticated tools in order to be ready to meet these requirements when the rule takes full effect. For example, in order to develop a discharge plan within 24 hours as the proposed changes require, case managers will need to find a way to sift through information about hundreds of different PAC providers quickly and efficiently. Luckily, software solutions exist now that allow case managers and other hospital workers to do just that—a comprehensive database with contact and geographical information, quality scores, medical and non-medical resources, and corresponding financial information for a variety of PAC providers.

Another critical feature of such a database, when it comes to meeting the requirements of the new CMS proposed rule, is that both the clinical care team and the patient and family members can access the database to make sense of the choices available. That’s because the new rule has a lot more focus on taking into account the patient’s input in their own care. “The proposed rule emphasizes the importance of the patient’s goals and preferences during the discharge planning process. These improvements should better prepare patients and their caregivers to be active partners for their anticipated health and community support needs upon discharge from the hospital or post-acute care setting,” says the CMS website. “In addition, patients and their caregivers would be better prepared to select a high-quality post-acute care provider, since hospitals, critical access hospitals, and home health agencies would be required to use and share data, including data on quality and resource use measures. This results in the meaningful involvement of patients and their caregivers in the discharge planning process.”

Case managers are committed to providing the highest quality and most complete post-acute care information to our patients. We realize the importance of patient and family buy-in of the discharge plan and its direct impact on keeping the patients from being readmitted to the hospital, and I believe that most of my colleagues support the proposed rulings in the IMPACT Act to help make this a reality. We also know, however, that it’s really difficult to access current, clean PAC data (that we trust) in an efficient manner. We need a resource database that not only provides lists, qualifications and special offerings of post-acute care providers but offers quality scores to help assure the case manager is creating the best discharge plan. We have a ways to go, but I’m confident that this type of solution will blaze a new trail for our patients and care team members.

About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 

 

 

References:

1. https://www.youtube.com/watch?v=LQpGMg2-bhQ

2. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-10-29.html  

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By: Stephanie Jackson  |  Type: Article  |  On: May 08, 2017

Leveraging CMS reimbursements for post-acute and chronic patients

With proper billing-code utilization and the right care-coordination technology to match the best providers with care seekers, physicians and health care organizations involved in the discharge planning and care coordination of chronic and post-acute patients can be reimbursed for these services.

Since 2015, the Centers for Medicare & Medicaid Services (CMS) has been reimbursing doctors and health care organizations for providing chronic care management. Unfortunately, many organizations are not receiving this reimbursement and may be missing out on federal funding for some of the sickest Medicare beneficiaries. With proper billing-code utilization and the right care-coordination technology to match the best providers with care seekers, physicians, and health care organizations involved in the discharge planning and care coordination of chronic and post-acute patients can be reimbursed for these services. 

What are the CMS reimbursements?

As reported by ModernHealthCare, CMS made payments for chronic-care claims for just 513,000 Medicare beneficiaries of the approximately 35 million individuals eligible for this program. (To be eligible, individuals must have two or more chronic conditions.) Some of this gap stems from physicians' overall lack of awareness of the billing code for care management. However, by speaking with physicians, coordinating chronic-care services and using the right care-management billing codes, CMS will reimburse physicians and health care organizations for their time. 

The source noted that approximately 70 percent of Medicare beneficiaries have two or more chronic conditions. Examples of the covered conditions include, but are not limited to:

  • Alzheimer's disease and related dementia.
  • Arthritis (osteoarthritis and rheumatoid).
  • Asthma.
  • Diabetes.
  • Hypertension.
  • Depression.
  • Cancer.

Hospitals that partner with acute care nurses, discharge planners and care coordinators can take advantage of the average $42 per patient per month reimbursement for chronic-care service coordination and specialist consultations.

As noted in ModernHealthCare, another reason some health care providers are not taking advantage of this opportunity is due to the necessary written patient permission for the reimbursements. However, the 2017 add-on now eliminates the need for written consent and allows a verbal okay from patients.

According to CMS, the payable CCM service codes include:

  • CPT code 99490: covers 20 minutes of clinical staff time once a month for patients with two or more chronic conditions at significant risk of death or functional decline. The chronic care management services are required to have established, implemented, revised or monitored a comprehensive care plan.
  • CPT code 99487: covers 60 minutes per month of clinical staff time for complex chronic care involving moderate or high complexity medical decision making.
  • CPT code 99489: covers additional 30-minute block for qualified clinical staff time, once per month.
  • HCPCS code G0506: an add-on, covers qualified clinical staff time for the initiating visit with a patient to develop a comprehensive assessment and care plan.

Some of the services included under the CCM cover:

  • Continuity of care with designated care team members.
  • Comprehensive care management planning.
  • Transitional care management.
  • Coordination with home- and community-based clinical service providers.

Qualified clinical staff include:

  • Physicians.
  • Certified nurse midwives.
  • Clinical nurse specialists.
  • Nurse practitioners.
  • Physician assistants.

CMS also noted that CCM services are priced in both facility and non-facility settings, including skilled nursing, nursing, assisted living or other facility settings.

Reducing patient hospital readmittance

Patient readmittance in the first 30 days results in a CMS reimbursement penalty, so it's imperative that discharge nurses have top quality care providers for post-acute and chronic patients.

Unfortunately, research studies showed that 17.3 percent of Medicare fee-for-service patients aged 65 and over were readmitted within 30 days in 2012, according to the National Health Statistics Report. Readmissions occurred due to care coordinators poorly managing transitions during discharge, infections or complications caused by the hospital stay or the reappearance of the condition that led to the hospitalization in the first place.

Reducing readmissions falls on care coordinators in charge of locating care providers with the skills and qualifications that best suit the needs of the patient.

To accomplish this, care coordination companies, such as hospitals or health IT companies, are building discharge-planning software. However, these platforms need a robust database of talented and experienced care providers to ensure post-acute and chronic patients recover quickly and do not need readmittance.

 

Care coordinators need to reduce the hospital readmission rate of chronic patients.

Care coordinators need to reduce the hospital readmission rate of chronic patients.

Follow-up calls between visits to primary care physicians

One way to help reduce the chances for chronic and acute patient readmission is to provide ongoing treatment and care following a hospital discharge. This enables an open dialogue and regular visits to ensure the patient is following the physician's recommendations. 

Individuals receiving ongoing treatments from their primary care physicians and suffering from two chronic conditions need extra care providers in between doctor visits. Aligning these care services along with the CMS reimbursement is important to capture lost revenue opportunities.

How Carelike can help

Sometimes the biggest obstacle to taking advantage of the CMS reimbursement is finding the best-suited care providers to deliver post-discharge and follow-up services. Matching a nurse without the right qualifications can lead to readmission, which penalizes the reimbursement. Often, as noted by the Center for Healthcare Quality & Payment Reform, the inability to receive good primary care support in the local community is a main contributor to preventable readmissions.

Care coordinators arranging for discharge planning or long-term follow-up services for chronic patients need easy access to a wide range of care providers. Further they need the ability to accurately tailor their searches to locate the most appropriate health care professional to align with unique care seeker needs. By identifying the best local care providers for managing post-discharge chronic care patients, hospitals can reduce their readmission rates and ensure they're receiving the full CMS reimbursement.

Carelike creates a custom portal for care coordinators, who can then use licensed data that focuses on either national or local/regional care providers. Hospitals that already have their own systems can rely on Carelike's API that simply plugs into existing systems for easy access to the extensive database.

Using Carelike's dashboard, care coordinators can easily track patient statuses, add noted, document care transitions and take advantage of the extensive database of providers who all manage chronic and post-acute conditions. This provides an additional layer of context during the transition phase that's crucial for communicating additional information about patients.

Companies in the process of building a software solution to meet the growing need of matching care providers with care seekers could benefit from using the Carelike database.

Carelike provides the technology and resources to help hospitals, health care organizations and care coordinators take advantage of CMS reimbursements for chronic care and post-acute care management. Click here to learn more about Carelike.

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By: Carelike Team  |  Type: Article  |  On: February 09, 2016

How has the ACA shaped Medicare?

Understanding the way the ACA has shaped Medicare is important for medical professionals considering the abundance of patients who use this form of health insurance.

The Affordable Care Act, which President Barack Obama signed into law in 2010, aims to reform the health care industry and give patients more control over their well-being. According to the U.S. Department of Health and Human Services, the main components of this legislation include accessibility, affordability and quality medical attention.

The ACA has made strides in these areas of health care, especially as it pertains to Medicare. Understanding the way the ACA has shaped this program is important for medical professionals considering the abundance of patients who use this form of health insurance. In fact, according to the National Committee to Preserve Social Security and Medicare, this government program benefits 52.3 million Americans. Learn more about how the ACA has impacted Medicare:

Physicians are switching to value-based payment

The implementation of the ACA has prompted the switch from the traditional pay-for-service model to value-based care, and Medicare has embraced this reimbursement method. The HHS released a timeline for this process in January 2015, highlighting that 30 percent of the pay-for-service model reimbursements are set to go to a value route like Accountable Care Organizations by the end of 2016. Meanwhile, HHS aims to tie 85 percent of the pay-for-service reimbursements to value through models like Hospital Value Based Purchasing in the same time frame. Both of those percentages are set to increase by the end of 2018.

“Whether you are a patient, a provider, a business, a health plan, or a taxpayer, it is in our common interest to build a health care system that delivers better care, spends health care dollars more wisely and results in healthier people,” said HHS Secretary Sylvia M. Burwell.

Doctors must prepare for this transition by acquainting themselves with value-based payment models, applying business principles and remaining knowledgeable on how they can deliver high-quality care to receive adequate compensation. Essentially, instead of a physician’s salary depending on the number of visits and tests ordered, Medicare will reimburse doctors based on the improvement of patients’ well-being.

Less expensive preventative services and prescription drugs

The Centers for Medicare & Medicaid Services explained that many Medicare beneficiaries fall into a coverage gap called the “donut hole.” Essentially, those using the Medicare Prescription Drug Plans may experience this dilemma after exceeding a spending benchmark on prescriptions. In 2016, that amount is $3,310. Through the ACA, CMS beneficiaries of Medicare Part D qualify for a 55-percent discount on brand-name medications when they reach this cap, which helps get them out of the “donut hole.” 

For doctors, this may mean that fewer patients will seek prescription payment assistance programs or depend on generic versions of prescriptions. Additionally, the Center for Advancing Health explained that patients who can’t afford prescriptions may simply forgo their treatment plans, which can put their overall well-being at risk. Physicians may experience more patients who are willing and able to stick to a care plan and, as a result, are more invested in their health.

Patients are seeing discounts in more than just their brand-name prescriptions. The CMS noted that the ACA also made many preventative tests and screenings free for patients. This covers a number of services including mammograms, colonoscopies, cardiovascular disease screening and glaucoma tests, among others. This means doctors may be able to order preventative services without worrying about the high costs for patients. To be sure, it’s important to scrutinize all details of a treatment plan, including price and alternative options, but at least with Medicare’s new pricing strategy, doctors can more readily take steps to protect patient well-being.

Medicare is protected now and in the future

The cost-reduction efforts from the ACA have prolonged the life of Medicare’s trust fund to 2030, according to the Medicare Board of Trustees annual financial review. This time frame extended 13 years beyond the one projected before the implementation of the ACA. The board attributed the slow growth of health care costs to decreases in fraud and overpaying, in addition to other economic savings. Essentially, doctors can expect to see patients with Medicare coverage for years to come.

It’s vital for doctors to stay on top of the latest heath care trends in order to deliver higher quality care while running a successful business.

 

Sources:

  • http://www.hhs.gov/healthcare/facts-and-features/key-features-of-aca-by-year/index.html#
  • http://www.ncpssm.org/Medicare/MedicareFastFacts
  • http://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html
  • https://www.medicare.gov/about-us/affordable-care-act/affordable-care-act.html
  • http://www.cfah.org/prepared-patient/pay-for-your-health-care/paying-for-prescription-medications
  • https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/
  • http://www.scribd.com/doc/272374231/Medicare-Board-of-Trustees-Annual-Financial-Review
  • http://healthleadersmedia.com/content/HEP-318821/Medicare-Trustees-Funds-Sufficient-Through-2030##
  • http://www.studentdoctor.net/2014/07/how-do-i-get-paid-a-beginners-guide-to-physician-compensation/
  • https://www.cms.gov/apps/files/aca-savings-report-2012.pdf
  • http://www.healthcarebusinesstech.com/value-based-timeline/
  • https://www.medicare.gov/about-us/affordable-care-act/affordable-care-act.htm
  • http://www.healthcarebusinesstech.com/aca-healthcare-trends/
  • https://www.whitehouse.gov/sites/default/files/docs/healthcostreport_final_noembargo_v2.pdf
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By: Carelike Team  |  Type: Blog  |  On: December 10, 2013

CMS Ratings - Informed Staff Improves Prospective Customer Experience

With so much emphasis on reform in today’s healthcare landscape, the CMS Quality Rating System is becoming increasingly important.

With so much emphasis on reform in today’s healthcare landscape, the CMS Quality Rating System is becoming increasingly important. The rating system has been widely publicized and, as a result, more and more consumers rely on this data during a search for a nursing home facility that can best serve their needs. When comparing facilities using the CMS rating system, a consumer may have questions for the staff about why a rating may be different from a competitor. For every facility, it’s important for staff to be well versed on how ratings are compiled, the rating for the location they work for, and how to answer questions about specific scores.

 

Getting To Know The Rating System

CMS created the Five-Star Quality Rating System as a tool for consumers, families and caregivers to easily compare facilities and identify available levels of care. The ratings cover three categories: health inspections, staffing, and quality measures. These categories deliver three individual ratings  and one overall rating.

 

According to CMS, on a scale of one to five stars, an overall rating of five is considered “much above average quality and nursing.” Although an overall score is provided, it is important to look at ratings for each of the evaluated areas and focus on areas of importance determined by the level of care required. It is also important to remember that facilities are rated for survey and staffing by state, which can vary wildly, so the system should not be used to compare a facility in one state to a facility in another.

 

Below is a brief overview of the components that comprise the Five-Star rating. These points should be used when speaking to residents and families regarding the rating system or an individual facility’s specific rating.

 

The staffing rating offers information about the number of hours of care provided to patients each day. This will vary based on the needs of the patients in the facility and the level of care required.

 

The health inspection rating sheds light on the last three years of on-site inspections. This in-person inspection evaluates to what extent the nursing home has met Medicare’s minimum requirements. The health inspection rating considers the number and the scope and severity of deficiencies.

 

If a consumer is interested in how well a facility is caring for its residents, they will want to know the rating for Quality Measures which has information on different physical and clinical measures such as ADL change, high-risk pressure ulcers, physical restraints and pain.

 

For more detailed information on the CMS Five-Star Quality Rating System, visit cms.gov.

 

When Potential Customers Have Questions About Your Rating

To more effectively interact with potential residents, nursing home staff should know the rating for their location and those of competitors in the area. This information can be found using the Medicare.gov

 Nursing Home Compare Tool. Staff familiar with the ratings of competitors will be more prepared for questions from potential residents.

 

Customers may want to know specifics like, “Why is the health inspection score from 2011 much lower than the following two years?” In situations like this, consider being transparent. Perhaps the score in 2011 prompted an internal assessment that led to much needed changes and reform. Sharing specific details of what was done to resolve the problem will provide the potential resident important insight into how a facility is managed and the priority it places on its residents.

 

For facilities that consistently rate higher than average, CMS ratings can be a badge of honor. The staff should understand how management and leadership ensure consistently high scores, whether through retention of well trained staff, ongoing staff training, or adhering to particular policies. Understanding the infrastructure in place for quality assurance will help families feel comfortable that the high rating can be expected to continue over time.

 

Families want a safe, secure, comfortable, and economical place for their family members to live where they will receive the highest quality care available for their needs. CMS quality ratings are an excellent tool to help choose the best and most affordable facility that will meet the needs of their loved one. If your staff is knowledgeable, the transition can be eased considerably—a win-win comfort level for both your facility and the families involved. 

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