Medicare
When are patients provided a MIM?
Upon admission as an inpatient and again within 48 hours of discharge.
When is an initial assessment due?
Is it ever appropriate to write a note with only one or two sentences? If no, why not? If yes, when would this be appropriate?
Yes. As a daily note when a discharge plan note is not due or the plan hasn't changed to provide a brief update on the discharge plan and any barriers.
When would you consider guardianship?
When a patient has been deemed incapable of making medical decisions for themselves AND there is no medical power of attorney and/or no Advance Directive AND there is no family available to act on behalf of patient.
What metric drives the date for follow-up appointments?
What responsibility does case management have when a patient is upgraded from observation/outpatient to Inpatient class?
If the patient has Medicare as a payor source, the case manager must deliver a MIM that day since it includes Hospital Inpatient Rights under Medicare as well as the Medicare Discharge Rights.
When will you complete a Readmission Assessment?
When a patient has been hospitalized within the last 30 days.
Only if inserting flowsheet data (i.e. transport arrangements). We do not ever use the "Create a Note" function at the bottom of our assessments.
Who do you contact to request guardianship consideration?
Fredericka Morgan via email - include all relevant information (email Desiree in her absence).
When are you required to place an order for "Ambulatory Referral to Complex Case Manager?"
For any patient with the following current dx: sepsis, PNA, Covid, PUI, CABG, CVA, and if they have hx of COPD and/or CHF. Also, patients who will d/c with any LDAs or may benefit from continued follow-up by CM.
On the signature line, print the name, relationship to patient, and phone number of the person receiving the information. Write date/time on that line. Case Manager signs (legibly) their name at the bottom. In iCare, you provide the relationship to the patient with a comment of person's name. Select "telephonic" and comment with phone number.
When are you required to complete Discharge Interventions? And why?
When you complete Initial Assessment and for any d/c plan update thereafter; when you provide an intervention listed - don't forget that SNF referral is an intervention.
Are PT/OT notes the deciding factor on if a patient is discharged to SNF/Rehab? Why or why not?
No. Therapy notes are a recommendation to the provider for the appropriate level of care. The provider asked for their recommendation when placing the order for PT/OT eval. The patient/family has the choice to decline SNF/Rehab as recommended and discharge home if they want.
Who completes the medical evaluation form?
The attending provider - CM may assist w/ demographics, PMH, medication list (only what's currently ordered). You may need to enlist the assistance of hospitalist team's nurse.
Why must the Expected Discharge Date be kept current and never expired/passed?
The Expected Discharge Date influences staffing levels (nursing, therapy, AMR, etc.), timing/scheduling of tests and procedures (such as 6-minute walks), patient movement/bed control, utilization review, reports, and other metrics.
Patients/representatives have 4 hours from time of delivery of a MIM to consider their appeal rights and cannot be pressured/rushed to discharge until then. If MIM is delivered within 4 hours of discharge time, you must explain to patient/representative they have 4 hours to consider the appeal process and document their understanding.
What are Riverside's two patient identifiers?
Name and date of birth. This must be verified prior to an assessment beginning and anytime you speak w/ patient/family over the phone.
How often are you required to update the Discharge Plan from within the CM Activity and write a correlating progress note?
Every 4 days. If the 4th day falls on a weekend or holiday, you must update the DC Plan and note prior to the weekend/holiday.
Who is Riverside's guardianship attorney?
Deb Holroyd
What does IPOC stand for?
Interdisciplinary Plan of Care
What do you do with a signed MIM? And how often?
Put in top tray next to copy machine in the office. They must be dropped off at the end of each day.
When and where do you document avoidable days?
When the patient is discharge ready and there is a delay in discharge that could have been avoided. The documentation is under Bed Days Coverage which is located on the Overview Report in the Summary Activity.
Provide step-by-step instructions for writing a Readmission Assessment, Initial Assessment, and Discharge Plan progress note.
Select "Progress Note" from the table of contents in the CM Activity; insert Smart Text, select the correct template from Favorites; Sign the note.
Do you continue to chart on patient's who are pending guardianship?
Yes - follow policy for documenting an update discharge plan.
What part of Medicare covers hospitalization, SNF, home health, and hospice?
Part A
Part B - covers DME and ambulance services
Part C - this is the Advantage Plan coverage
Part D - drug coverage