Lunch & Learn Sentara Care Coordination Sally Sekowski, RN, MSN, ACM Director, Care Coordination Sentara Healthcare Sherry Parker, LCSW, ACM Manager, Social Work Services Sentara Healthcare September 19,

A Vision of Change – February 2011 the Journey Begins patient Our patients Sentara Hospitals Access Care Coordinators Continuum of Care Providers Multi-disciplinary Teams Unit Based Care Coordination Team VPMA’s/Physician Advisors Resource Management Center 2

© T H E A D VISO R Y BOA R D C OMPA N Y Crafting a Comprehensive Case Management Strategy 1) Sample staff included in rounds are physicians, nurses, physical therapists, nutritionists, etc. 1 Inpatient Redesign First Step in Improving Ability to Support Broader Efforts Multifaceted Case Management Approach at Sentara Healthcare Phase II Revitalized Multidisciplinary Rounds: Representatives across different clinical disciplines collaborate to conduct joint rounds and create a patient- centered care plan 1 Care Coordination Dyad Model: Social worker and care coordinator paired to improve coordination of care; staffing ratios re-evaluated to ensure adequate support Access Coordination: Case managers embedded at all points of patient access (e.g., ED, OB, etc.) to ensure appropriate level of care provided Resource Management: Centralized corporate office conducts utilization review, discharge planning Medical Necessity Reviews: VPMA advisors, with support from external agency, reviews cases, interfaces with medical staff Phase IPhase III Post Acute Partnerships: Case management leaders will collaborate with post-acute care providers to improve transitions, information exchange, unnecessary transfers Enhanced Technology: Case management system evaluation underway Care Coordination Practice Council: New cross-continuum committee will integrate inpatient, ambulatory-based, and health plan case managers to improve communication and best practice sharing 3

Resource Management Center- Our UM Hub for 7 hospitals RMC Compliance and Auditing Utilization Management Discharge Facilitation Resource Staffing Pool 4

At the access points of the hospitals, RNs assess patients to determine medical necessity and provide transition planning. The use of MCCM enables the RMC staff to seamlessly provide additional clinical information as needed or if a physician review is required. 5 Access Coordinators

Care Coordination Dyad – Nurse and Social Worker Team Approach – daily huddles Coverage - 7 days per week Plan of the Day /Plan of the Stay 6 Hospital Based Care Coordination Team

Appropriate Social Work Referrals All placements: (SNF, NF, LTAC, Acute Rehab, Adult Home/Assisted Living, Shelters) –Ventilator –CVA with paralysis –Fractures/Replacements of Hips and Knees (if criteria met) –Elderly / frail/ living alone / inadequate social support –Homeless –Psychiatric (suicidal, in need of acute psychiatric hospitalization) APS/CPS/ Domestic Violence Patients/ family members in need of support and crisis counseling due to traumatic injury and /or medical condition Patients experiencing Post-traumatic stress symptoms (nightmares, reliving events, depression, guilt) Maternal Health Updated 3/12/2013 7

Freedom of Choice 8

Request Form 9

Vendor Policy 10 Scope External company data network connections to Sentara can create potential security exposures if not administered and managed correctly and consistently. These exposures may include non-approved methods of connection to the Sentara Healthcare network, the inability to shut down access in the event of a security breach, and exposure to hacking attempts. This standard applies to all vendors, including all personnel affiliated with vendors. When vendor connections do not meet all of the guidelines and requirements outlined in this document, they will be re-engineered or disconnected as needed. Business Justification Remote access into Sentara’s internal network will be approved based on business need and system availability. Appropriate justification would include, but not limited to, vendor support for a specific application or system. Available Technologies Sentara will only provide applications and access in accordance with the contract on file. The preferred technology for vendor remote access is metaframe connectivity. This would be accessed via the internet using a posted URL address. All vendor metaframe access will be authenticated (i.e., ID and password).

Inpatient or Outpatient??

Outpatient or Outpatient with Observation Services Outpatient Observation MedicareCommercialMedicaid CMS Guidelines Everyone does it differently Very limited

Medicare Claims Processing Manual Chapter 4; ( ) Observation Services Defined Well defined set of specific, clinically appropriate services, which include: –Ongoing short term treatment; –Assessment, and –Reassessment…

Medicare Claims Processing Manual Chapter 4; ( ) Observation Services Defined ….before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Medicare Claims Processing Manual Chapter 4; ( ) “Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision regarding admission or discharge.”

CMS 2014 Inpatient Prospective Payment System (IPPS) Final Rule

Overview of IPPS 2 Midnight Rule for Inpatients Published: August 19, 2013 Effective: Oct. 1, 2013 Applies to all Inpatient and critical access hospitals Inpatient psychiatric hospitals excluded 17 Sept.12, 2013

Physician Certification Requirements Authentication of the practitioner order Reason for the Inpatient services/ treatment or diagnostic study; “Special or unusual services” the patient will receive The estimated time the patient will stay in the hospital Plans for post-hospital care, as appropriate 18 Sept.12, 2013

Skilled Nursing Facility Placements Still requires 3 Inpatient Midnights- no change ED or Outpatient Observation Midnights do not count towards SNF placements 19 Sept.12, 2013

QUESTIONS? 20

Contact Information 21 Sentara Care Plex Care Coordination Manager: Quijuana Goodman Sentara Obici Care Coordination Interim Manager: Charlene Russell Sentara Healthcare: Sally Sekowski Sherry Parker

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