THE HOSPITAL CASE MANAGEMENT ORIENTATION MANUAL

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Peggy A. Rossi, BSN, MPA, CCMReviewed by Karen Zander RN, MS, CMAC, FAANThe Hospital Case Management Orientation M anualprovides comprehensive information to help newand e xperienced case managers face the myriad of challenges that comprise a typical day.It offers advice for locating community resources and includes examples of how to document information.The online a ppendix provides links to websites with helpful information.ROSSIThis book is simultaneously a teaching tool for newcase m anagers and an essential resource for seasonedprofessionals.THE HOSPITAL CASE MANAGEMENT ORIENTATION MANUALTHE HOSPITALCASE MANAGEMENTORIENTATION MANUALTHE HOSPITALCASE MANAGEMENTORIENTATION MANUALHCMOMRGPeggy A. Rossi, BSN, MPA, CCMa divisionof BLR75 Sylvan Street Suite A-101Danvers, MA 01923www.hcmarketplace.comReviewed by Karen Zander RN, MS, CMAC, FAAN

THE HOSPITALCASE MANAGEMENTORIENTATION MANUALPeggy A. Rossi, BSN, MPA, CCMReviewed by Karen Zander RN, MS, CMAC, FAAN

The Hospital Case Management Orientation Manual is published by HCPro, a division of BLR.Copyright 2014 HCPro, a division of BLRAll rights reserved. Printed in the United States of America.5 4 3 2 1ISBN: 978-1-61569-291-0No part of this publication may be reproduced, in any form or by any means, without prior writtenconsent of HCPro, a division of BLR, or the Copyright Clearance Center (978-750-8400). Please notifyus immediately if you have received an unauthorized copy.HCPro provides information resources for the healthcare industry.HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO andJoint Commission trademarks.Peggy A. Rossi, BSN, MPA, CCM, AuthorErin Callahan, Senior Product DirectorElizabeth Petersen, Vice PresidentVincent Skyers, Design ManagerMichael McCalip, Layout/Graphic DesignKaren Zander RN, MS, CMAC, FAAN, ReviewerMelissa Osborn, Product DirectorMatt Sharpe, Production SupervisorVicki McMahan, Sr. Graphic DesignerKelly Church, Cover DesignerAdvice given is general. Readers should consult professional counsel for specific legal, ethical, orclinical questions.Arrangements can be made for quantity discounts. For more information, contact:HCPro75 Sylvan Street, Suite A-101Danvers, MA 01923Telephone: 800-650-6787 or 781-639-1872Fax: 800-639-8511Email: customerservice@hcpro.comVisit HCPro online at www.hcpro.com and www.hcmarketplace.com

ContentsAbout the Author.ixAbout the Reviewer.xiForeword. xiiiChapter 1: Case Management Basics. 1Definitions. 1Goals of an Effective Case Manager. 3Core Competencies. 3Why Case Management Assessment Is Important. 6Preventing Readmissions. 7Networking and Collaboration. 11Hospital Case Management Models. 12Typical Activities of an RN Case Manager. 13Typical Activities of a Social Worker Case Manager. 13Labor, Delivery, Newborns, and NICU. 16Emergency Department Case Management. 17Establishing Daily Workflow. 18The Handoff Process. 21Best Practices. 22Chapter 2: Factors Influencing Case Management and Its Processes.25Laws That Affect Case Management. 25Mandatory Reporting of Suspected Abuse. 27Risk Management and Malpractice. 28Standards of Care. 30Health Literacy. 31Interpreter Services. 31Documentation Requirements. 32Case Management Documentation. 35Medicare Conditions of Participation. 36Reassessment. 36Documentation of Post-Acute Care Transfers. 38Other Documentation Concerns. 38Documentation Protocol. 39Determining and Declaring Decision-Making Capacity. 40Conservatorship. 42Persons Who Are A Danger to Themselves or Others. 42Advance Healthcare Directives. 43Physician Orders for Life-Sustaining Treatment. 43Charity Funds. 44 2014 HCProThe Hospital Case Management Orientation Manualiii

ContentsDischarge Refusal. 44Leaving Against Medical Advice. 46Dental Care. 47Leave of Absence. 47Patients with Infections. 48Abandonment. 48Adoptions. 48Best Practices. 49Chapter 3: Healthcare Funding.51Funding, Reimbursement, and Alternative Funding Resources. 51Coverage Exclusions. 52Reimbursement Methodologies. 53Managed Care. 55Other Managed Care Insurer and Third-Party Payer Terms. 55Medicare. 56Medicaid. 58Medical Indigent Assistance Program. 58Medicaid and Presumptive Disability. 59Restricted Medicaid. 61Medicaid Waivers. 62Social Security Disability Income. 64Supplemental Security Income. 66Maternal, Child, and Adolescent Services Programs. 67Developmentally Disabled Services. 68Special Education. 70TRICARE. 71TRICARE for Life. 72U.S. Department of Veterans Affairs. 72CHAMPVA. 75Dual Eligible Funding. 75Other Insurers and Potential Third-Party Payers. 76Victims of Violent Crime. 78Best Practices. 80Chapter 4: Utilization Review and Utilization Management.81Reviewer Roles. 83The Role of the Physician Advisor. 83Initial Reviews. 85Inpatient Status and Patient Admissions. 89Concurrent Reviews. 90Retrospective Reviews. 93Discharge Reviews. 93Labor, Delivery, Nursery, and NICU Utilization Reviews. 93Emergency Department Utilization Review. 94ivThe Hospital Case Management Orientation Manual 2014 HCPro

Contents 2-Midnight Rule. 94Physician Certification. 95Observation . 96Direct Admissions. 101Condition Code 44. 102TARs, PARs, and SARs. 103Avoidable Days or Events. 103Out of Network. 104Best Practices. 105Chapter 5: Letters, Denials, and Appeals. 109Letters. 109Important Message from Medicare Letter. 109Hospital-Issued Notices of Noncoverage. 114Reinstatement Letter. 115Medicare Benefit Exhaust Letter. 116Advance Beneficiary Notice. 117Noncoverage Letters Issued by an Insurer, Third-Party Payer, or Medical Group. 117Other Denials. 119Appeals. 121Insurer and Third-Party Payer Letters of Agreement. 122Charity Funds and Letters of Agreement. 123Best Practices. 123Chapter 6: Care Coordination. 125Teamwork. 126Daily Multidisciplinary Care Coordination Rounds. 127Complex Care and Long-Stay Rounds. 128Case Conferences. 130Discharge and Transition Plans for Patients in Intensive Care. 131Patient Choice. 132Developing a Transition Plan. 132Financial Planning. 135Unsafe Discharges. 136Noncompliance. 139Homeless Patients. 139Medications for Homeless and Medically Indigent Persons.

CASE MANAGEMENT ORIENTATION MANUAL. THE HOSPITAL CASE MANAGEMENT. ORIENTATION MANUAL. P. eggy A. Rossi, BSN, MPA, CCM. Reviewed b. y Karen Zander RN, MS, CMAC, FAAN Th. e Hospital Case Management Orientation Manual provides comprehensive information to help new and experienced case managers face the myriad of challenges that comprise a typical day.

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