A good doctor has to understand how the healthcare system works. Similarly, to provide optimal care for your patients you need a working knowledge of key hospital rules and requirements. The following tutorial has been prepared to give you some basic information to help you serve your patients better and maintain the smooth functioning of the hospital.

There are three sections to the tutorial:

The tutorial combines short informational paragraphs with related multiple-choice questions. As you click on your response, the tutorial will indicate the correct choice. It will take about 20 minutes to complete this session.

When you complete the session, you must send an e-mail as instructed at the end of the tutorial. In addition, you may print a certificate of completion for your records. Your Department Chairman may instruct you to submit a copy of the certificate for your departmental file.

Begin below:

Optimal clinical care involves more than identifying the correct diagnosis and providing the right treatment; it requires (a) making sure each patient receives the appropriate type and level of care at the appropriate time; and (b) that all of the patient’s needs are completely and accurately documented in the chart and successfully communicated to the patient, family, and hospital staff. One important aspect of this is effectively anticipating the patient’s hospital discharge, since coordinating all the necessary steps and services ordinarily requires a few days of preparation. It involves early and specific discussions with the patient and family, and timely consultation with the social worker and other hospital staff, who can arrange suitable post-hospital care.

Similarly, during the patient’s hospital stay, optimal clinical management encompasses efficient scheduling of tests and treatments, to allow the patient’s return to the comfort and safety of home or other non-acute-care setting as early as possible. Good clinical management also requires carefully documenting the patient’s condition, particularly the clinical criteria that justify continued hospitalization. Otherwise, the patient may face insurance coverage difficulties, and the hospital and attending physician may be denied payment.
 
 

The Social Work Department at NYULMC provides psychosocial counseling to assist patients and their caregivers in managing the impact of illness, disability, hospitalization.  On each unit of the hospital, you will find a social worker to assist your patients, their families and caregivers in developing a discharge plan should post-hospitalization care be needed.   Discharge Planning is, for many of our patients, an extremely important function that needs to begin as soon as you suspect that a patient may need post-hospital care.

When you realize that a particular patient may need assistance, you should inform patients and their families that a social worker is available to meet with them.    The social worker can provide them with information and referrals for community resources, including home care, nursing homes, rehabilitation programs and other levels of care.

Q1.  The social worker will assist the patient and caregiver in

A. Formulating a plan for post hospital care
B. Provide referrals for public entitlements and community resources, including home care or long-term care
C. Identify appropriate support programs
D. All of the above

Not all patients qualify for home care.  Strict standards are applied by home care agencies: the patient must need skilled nursing or require physical therapy.  In addition, they may be eligible for occupational therapy, speech therapy or a home health aide, as determined by the home health agency.   Contact the Social Worker who will help in making this assessment.

Should a patient receive home care, the attending physician will be responsible for follow-up orders in the community.  Lab work results received after the patient is discharged will be sent to the attending physician’s office for review.

Arrangements can be made for patients who need infusion care at home, but because such referrals are often difficult, contact the Social Work and Discharge Planning Nurse in the Department of Social Work as soon as possible. 

Q2.  Every patient has the right to home care services. Which of the following is the best answer.

A. Every patient has the right to home care services.
B. Not everyone can assume that they will receive home care.
C. There must be some demonstration of a patient's need for skilled nursing or their ability to respond to physical therapy.
D. The Discharge Planning Nurse will determine if home care is appropriate.

Unnecessary delays in assisting patients with their discharge can be avoided if you contact the social worker as soon as it is apparent that the patient will need help with meeting their post-hospitalization needs.  Social work can order equipment and assist patients in arranging for transportation.  To order an ambulance, social work will need you to verify that it is medically necessary for the patient.  If the patient does not need an ambulance, social work can arrange for an ambulette or car service (at the patient’s expense).

Social work provides information to assist patients in accessing public assistance programs, such as Medicaid.  They also help patients in understanding the complexities of insurance coverage.

 Q3. My patient is 86 years old and lives alone.  He will need a walker and a wheelchair, as well as an ambulette for getting home.  In addition, he will need infusion care. 

a) Who do I call to assess the feasibility of my patient receiving infusion care at home? 

 A.  the patient’s son
 B.  a home care agency
 C.  the social worker
 D.  the discharge planning nurse
 E.  C and D
 
b) Who do I call to obtain the equipment that he will need and help to get him home?

 A.  the patient’s son
 B.  a home care agency
 C.  the social worker
 D.  the discharge planning nurse
 E.  C and D
 

Other levels of care besides home care are sometimes appropriate for patients.  Confusion over eligibility, and the need to obtain referrals, can take valuable time when arranging the right level of care for the patient. 

At minimum, you should be aware that a referral to any particular facility, or type of facility, can be complicated and time consuming. 

Acute rehabilitation is appropriate for patients who can participate in at least 3 hours of day of physical therapy, occupational therapy and speech therapy,.  Subacute rehabilitation is generally offered in nursing homes to patients who expect to be able to go home within thirty days, need less therapy than in an acute rehab but require some medical care, such as IV antibiotics.  Nursing homes provide skilled nursing care or custodial care to patients with longer-term or heavy needs such as vent dependency, decubiti, or hemodialysis.  Patients who require TPN or expensive drugs such as epogen and neupogen often take longer to place in nursing homes.   Assisted living facilities generally require an upfront financial commitment and are designed for the higher functioning patient.  Hospice is a specialized home care program for patients who require end-of-life care. 

Call the social worker.  This is their area of expertise.  Make sure that they are in touch with your patients who may need help in distinguishing which level of care is best for them.
 

Q4    My patient needs rehabilitation treatment but is medically frail and can tolerate only two hours of therapy.  He is eligible for: 

A.  Acute rehabilitation (i.e., Rusk)
B. Rehabilitation in a nursing home
C. Home care
D. An extended hospital stay
E. Rehabilitation in a nursing home and home care.
F. Rehabilitation in a nursing home and extended hospital stay.

If your patient lacks capacity to make a discharge plan and has no family or friends, call the social worker.  It will be necessary to get a psychiatric consult to verify that the patient does lack capacity and will need someone to assist with arranging a discharge plan.  These types of cases are called guardianships and require legal intervention and an order from the court before the patient can be discharged.  This can be a lengthy process.

Q5.    My patient seems confused and unable to understand the discharge plan.  No family is available to discuss the plan.  I should first:

A.  Notify the social worker to discharge the patient to a nursing home.
B. Call the hospital lawyer for a legal evaluation of the case.
C. Tell the nurse caring for the patient to call a social worker.
D. Notify the social worker and request a psychiatric consultation.
E. Notify the social worker and call the hospital lawyer.

In the course of planning for your patient’s discharge, you may be required to fill out certain forms and applications such as an M11Q.  This is a form for Medicaid patients to receive extended home care hours.  An Inter-institutional Transfer Form needs to be completed for all patients going to a nursing facility, including sub-acute and long term.

Q6.  My patient is going to a nursing home.  I need to complete

A. an M11Q
B. an inter-institutional transfer form
C. a PRI
D. a continued stay discharge notice
 
 

Utilization management is a process designed to ensure that the delivery of health care services are medically necessary, cost-effective and efficient, are at the appropriate level, and meets professionally recognized standards of care. Both providers (hospitals) and insurance carriers (Medicare, Medicaid, managed care companies, commercial carriers) perform this function.

Hospitals are required by federal regulation to have utilization management programs in place to monitor the quality of patient care and the efficient use of resources. Utilization management programs fulfill the mandates of the Health Care Financing Administration, the New York State Department of Health, the Joint Commission on Accreditation of Healthcare Organizations and insurers.
 

Q1. What is utilization management?

A) A process designed to ensure that the delivery of health care services is medically necessary.
B) A process designed to ensure that the delivery of health care services is cost-effective, efficient and delivered in the appropriate setting.
C) A program designed to manage utilization of outpatient resources.
D) Both A and B.
E) Both B and C.
 

Q2. Hospitals and insurance companies both perform utilization management.

 True
 False
 

Q3. Why do hospitals have utilization management programs?

A. To monitor the quality of patient care and the efficient use of resources.
B. To meet the mandates of the Health Care Financing Administration.
C. To meet the mandates of the New York State Department of Health.
D. To meet the mandates of the Joint Commission on Accreditation of Healthcare 
E. All of the Above.
 

Quality Assessment (QA) Nurse Specialists at NYU Hospitals Center are responsible for performing concurrent utilization management for all inpatient admissions.

The process begins in the Admitting Department with the Pre-Admission Nurse Specialist who conducts screening and assessment of each elective patient’s reservation information, including transfers to and from Rusk Institute and from other facilities. This screening is done to assure that the planned admission is medically necessary, that the care will be delivered in the appropriate setting (e.g., inpatient, outpatient or ambulatory surgery), and that the admission is within an appropriate timeframe (i.e., surgery scheduled for the same day as the patient’s admission).

The QA Nurse Specialists perform medical record review for all admissions on the first working day after admission to identify the patient’s diagnosis, past medical history, reasons for admission, and the treatment/discharge plans. The QA Nurse Specialists also identify and document occurrences for the New York Patient Occurrence Reporting and Tracking System (NYPORTS) for investigation by the Clinical Risk Management Division on admission and all during the patient’s hospitalization.

After the initial admission review by the QA Nurse Specialists, concurrent review is performed every three to seven days during the remainder of the patient’s hospitalization to determine the reasons for continued hospitalization. The timing of each continued stay review is determined by the documentation in the medical record of the patient’s clinical status.

In addition, the QA Nurse Specialist staff provides concurrent and retrospective telephonic clinical information to case managers from the insurance companies for all managed care patients. For many of the cases being reviewed, the carrier requests a daily update of the patients’ clinical status to certify continued hospitalization and to identify the discharge plan. Case managers from three of the managed care companies (Aetna, Cigna, and Oxford) have been placed on-site at our hospital to perform utilization management for their patient populations.

Medicare and Medicaid patients are not reviewed concurrently by their insurer. However, retrospectively, the federally mandated peer review organization for New York State, the Island Peer Review Organization (IPRO) performs utilization management review for these patients.

Q4. Who performs concurrent utilization management at NYU?

A)  QA Nurse Specialists.
B)  QA Nurse Specialists and case managers from the managed care companies (including the on-site case managers from Aetna, Cigna and Oxford).
C)  QA Nurse Specialists and Social Workers.
D)   Social Workers.
 

Q5. What types of review are performed for utilization management?

A) Pre-admission Review.
B) Peer Review.
C) Admission Review.
D) Continued Stay Review.
E) All of the above.
F) A, C, and D
 

Q6. Which insurance types are reviewed retrospectively by the Island Peer Review Organization (IPRO)?

A) Empire Blue Cross Blue Shield
B) Medicare
C) Medicaid
D) Physician Health Services
E) Both A and D
F) Both B and C
 

Documentation is the key to the review process. When documenting the patient’s clinical information, it is important to be aware of the sources in the medical record that our QA Nurses and the managed care case managers review to determine if a patient’s hospitalization is medically necessary. These sources include the physicians orders and progress notes, nurse practitioners and registered nurses notes, operative reports, medication sheets, and test results (laboratory, radiology, etc.).

When a patient is admitted, the physician must complete an initial admission note and the history and physical within 24 hours. This documentation should include the following:

• Admission Note
• State admission diagnosis(es)
• Support inpatient admission:
• H&P/signs and symptoms
• Test results
• Treatment plan

• Daily Progress Note
• Patient assessment and response to treatment
• Test results and plans for addressing abnormal findings
• Plan for continued care
• Discharge plan

A) Physicians’ Orders and Progress Notes
B) Nurse Practitioners and Registered Nurses’ Notes
C) Operative Reports
D) Test Results (Laboratory, Radiology, etc.)
E) Medication Sheets
F)  All of the above
 

Q8. Physicians are required to complete an initial admission note and the history and physical within 24 hours after a patient is admitted. Thereafter, a daily progress note must be written to document the medical necessity for inpatient care.

True
False
 

Q9. What should you be documenting in the medical record to justify the medical necessity for inpatient admission and continued hospitalization?

A) On admission, the admitting diagnosis, including the 
clinical justification for inpatient services, all findings on history and physical exam, available test results, and your treatment plan.
B) In your daily progress note, include the patient assessment and response to treatment, test results and plans for addressing abnormal findings, the plan for continued care, and your discharge plan.
C) Recommendations for performance improvement.
D) All of the above.
E) Both A and B.
 

Q10. The physician must document the medical necessity for inpatient care daily.

True
False
 

Inadequate documentation from the physician can lead to a reimbursement denial from the insurers. If you find yourself documenting the following types of conditions, most likely the patient no longer belongs in an acute care setting:

• Afebrile-VSS
• Doing well
• Awaiting transfer
• Condition stable
• OOB ad lib
• Procedure/test cancelled (without clinical indication/justification)

Some of the reasons for medically unnecessary hospital days include the following:

• Delay in services (e.g., diagnostic testing, surgery, and discharge)
• Inpatient procedures/tests that should have been performed on an outpatient basis
• Insufficient documentation
• Inattention to prompt discharge
• Incomplete medical records

• Inconsistencies between physicians’ progress notes and nurses’ notes (e.g., physician order/note states “bedrest,” nurse’s notes state “OOB ambulatory.”
• Progress notes stating that the patient requires inpatient hospitalization for a specific indication (e.g., glucose monitoring every two hours) when ordering and monitoring are not done.

Subsequently, if you find yourself documenting these types of conditions, most likely the patient does belong in an acute care setting.
 

• Inability to void
• Severe pain requiring parenteral analgesia (4x24 hours)
• NPO status with IV hydration greater than or equal to 100 cc/hr
• Vomiting requiring parenteral antiemetics (4x24 hours)
• Febrile (temperature greater than or equal to 101degrees F)

A) Afebrile-VSS
B) Doing well
C) Awaiting transfer
D) Condition stable
E) OOB ad lib
F) Procedure/test cancelled (without clinical indication/justification)
G) All of the above
 

Q12. What are the most common reasons for “medically unnecessary” hospital days?

A) Delay in services (e.g., diagnostic testing, surgery, and discharge).
B) Inpatient procedures/tests that should have been performed on an outpatient basis.
C) Insufficient documentation.
D) Inattention to prompt discharge.
E) Incomplete medical records.
F) All of the above.
 

Q13. Which of the following statements will most likely indicate that your patient belongs in an acute care setting? Select all that apply.

A) Inability to void
B) Severe pain requiring parenteral analgesia (4x24 hours)
C) NPO status with IV hydration greater than or equal to 100 cc/hr
D) Vomiting requiring parenteral antiemetics (4x24 hours)
E) Febrile (temperature greater than or equal to 101degrees F)
 

Test Your Knowledge. Try Your Hand At This!
 

This 52 year-old female with a history of lymphoma in remission status post chemotherapy and autologous bone marrow transplant was admitted on 9/28/00 with disseminated herpes zoster and was placed on intravenous Acyclovir. The MD notes on 9/30/00, “Pt. feeling well. Rash much improved.” On 10/1/00, the MD notes “Pt. afebrile - improving… skin: vesicles crusting. WBC = 4.1… suggest to continue Acyclovir for 7-10 day course intravenously.” On 10/3/00, the MD notes: “Facial/trunk lesions mostly resolved, decreased erythema of right sacral area and with crusting.” The patient was discharged on 10/6/00.
 

Q14. Would you reimburse this claim?

A) Reimburse the days 9/28/00 through 10/4/00.
B) Deny the days 10/4/00 through 10/6/00.
C) Reimburse the entire admission.
 

This is an 80 year-old male with a past medical history of bladder cancer, CAD, atrial fibrillation, hypertension, CABG, and AAA repair. On 2/16/00, he presented to the ER at 11:10 pm with a temperature of 101.9 degrees. The patient had bladder irrigation prior to admission with Interferon/BCG and experienced chills and fevers to 102 degrees, two hours after the bladder manipulation. In the ER, the patient was found to have a temperature of 101.9 degrees and was started on IV Ampicillin and Cefepime. He was transferred to the Medicine Service on 2/18/00. The infectious disease specialist notes on 2/18/00, “If the patient remains afebrile, he can be changed to Levaquin 250 mg po daily.” The patient was changed to Levaquin 250 mg po daily on 2/19/00. On 2/19/00, his blood pressure increased to 200/100, which was associated with headache. The patient was given Cardizem and his blood pressure dropped to 190/90, but it is documented that the patient was alert, oriented only to self, had an unsteady gait, and had inappropriate responses. The nurse’s note states that the patient was confused and had a blood pressure of 192/104, which was treated with oral Hydralazine. By 5:00 pm, the patient’s blood pressure had decreased to 145/63 and he was cleared for discharge on 2/19/00.
 

Q15. Would you reimburse this claim?

A)  Reimburse the days 2/18/00 through 2/19/00.
B)  Deny the days 2/18/00 through 2/19/00.
C)  Deny the entire admission.
 
 

Copy then paste this note in the e-mail at the link below:   I have successfully completed the House Staff Tutorial! Please be sure to include your department. In the subject line, type:  House Staff Tutorial Notification of Completion of Tutorial   Congratulations -- You have successfully completed this tutorial!  Go treat yourself to a cappucino! Click Here and Print this certificate for your records