CMSA Today - Issue 2, 2012 - (Page 18)

Acute Care Series The Evolving Role of Care Coordination in an Acute Care Environment: Confirming the Appropriate Utilization of Necessary Services – Separating Tasks from Process PART 2 OF 3 BY NANCY SKINNER, RN-BC, CCM and B. K. KIZZIAR, RN-BC, CCM, CLCP This article is PART 2 of a 3-PART SERIES. The final article will provide insight into the demanding and often unscripted role of the acute care case manager with significant focus on the delivery of care coordination services as the patient moves through and beyond an acute care experience. T he delivery of care in an acute care facility sometimes launches a perfect storm of events that can compromise both patient safety and consumer satisfaction. This is a storm that not only touches the patient, family, and caregiver, but also impacts the ability of a hospital or any other health care delivery system to achieve the goals of balancing quality and fiscal accountability with a mission of meeting the needs of the community and the population it serves. As hospitals endeavor to achieve this multifaceted goal, case management interventions have been recognized as a vital component in all processes associated with gaining that balance and fulfilling that mission. Because there is no “one size fits all” delivery of case management CMSA TODAY interventions within the acute care facility, the role of hospital-based case managers is often defined by a job description that includes both a requirement to provide information that supports the appropriateness of necessary services and to facilitate an appropriate transition of care. In every way, this dual role is becoming more and more integral to harnessing the destructive winds of that perfect storm. The patient’s journey through this potential storm and into treatment begins with obtaining access to services and the initial portal to those services is rarely consistent. While the majority of patients present through the emergency department, other avenues of entry can include: direct admissions, scheduled admissions associated with surgery or procedures of some type, and the unscheduled admission following what was scheduled as an outpatient procedure. To maintain fiscal viability, every hospital, at every access portal, must develop a process that assures the careful scrutiny of each patient’s unique health status and required services before identifying them as inpatients. The choices are simple: inpatient or observation. Medicare offers four basic factors to assist in reaching an appropriate determination of that status: • The severity of the signs and symptoms exhibited by the patient • The medical predictability of an adverse event occurring if the patient is not admitted • The need for diagnostic studies • The availability of diagnostic procedures at the time and location where the patient presents. Measurement of these considerations is usually supported by standardized clinical criteria such as InterQual or Milliman. Those findings must also be included in the initial documentation by the physician. Absent that, there is no clinical rationale to justify the inpatient admission. The initial receiving physician is generally responsible for making a preliminary determination regarding classification for admission 18 ISSUE 2 • 2012 • DIGITAL

Table of Contents for the Digital Edition of CMSA Today - Issue 2, 2012

2012 Public Policy Summit, April 23-24
Aligning Professional Ethics with Innovation: Licensure Portability’s Predicament
Can You Hear Us Now? What’s Happening with the Multi State Licensure Task Force
The Evolving Role of Care Coordination in an Acute Care Environment: Confi rming the Appropriate Utilization of Necessary Services – Separating Tasks from Process (Part 2 of 3)

CMSA Today - Issue 2, 2012