▪ Inpatient RN Care Managers ▪ Social Workers ▪ Utilization Review RN ▪ Care Management Assistants ▪ Leadership ▪ Director ▪ Managers (CSM) ▪ Leads **Delineation/Utilization guides can be found in the box for RN, SW, and CMA roles.** Box→Care Management→Staffing Model Guides
▪ Completed by RN Care Manager or Social Worker ▪ Includes the following: • Clinical Picture • Plan of care • Behavioral concerns • Coping skills and deficits • Viability in present living setting • Social support • Evidence of abuse, neglect, exploitation • Substance abuse • Mental health issues • Services patient is receiving • Review past 30 days of EMR ▪ Initiated within 36 hours from time of admission/observation order ▪ Exceptions: • Planned Cesarean Sections/Vaginal deliveries • Short-stay patients who admit late in the day and discharge early the next morning • Those who are unable to participate in the assessment and do not have a next of kin identified. Policy PS.1.06
▪ Completed by RN Care Manager or Social Worker ▪ Completed every 72 hours ▪ Exceptions: ▪ Patients with extended LOS require reassessments every 5-7 days ▪ What should I include? ▪ Plan for discharge ▪ Barriers to discharge ▪ Evidence patient’s goals and treatment preferences have been addressed Policy PS.1.06
▪ Completed by RN Care Manager or Social Worker ▪ Completed within 24 hours of discharge ▪ What should I include? ▪ Discharge Disposition Policy PS.1.06
▪ Observation Patients ▪ Medicare Outpatient Observation Notice (MOON) must be provided to all Medicare beneficiaries when in observation status >24 hours ▪ Inpatient ▪ Admission Important Message from Medicare (MIM) is provided by admissions ▪ We need to document that this was done in the Initial Assessment Navigator [email protected] Don’t Skip!
▪ Does the patient need surgery? ▪ Is the patient still receiving treatment? (IV antibiotics, tube feeds, IV pain medicine, high oxygen requirements)→LTACH ▪ Has patient been evaluated by PT/OT/ST? What are their recommendations? ▪ Does the patient need/have 24 hour assistance? ▪ Is the patient tolerating a diet or have alternate source of nutrition? ▪ Is the patient being followed by Infectious Disease? ▪ Does my patient have a wound vac, drain, dressing change, etc… Pro Tip: You DO NOT need an order to begin planning.
▪ Not needed when going to acute level of care or any disposition with hospice care ▪ Inpatient Acute rehab, LTACH, inpatient hospice, outside hospital ▪ Can be completed 48 hours prior to discharge ▪ Patient has 4 hour window to contemplate appealing discharge 1 2 3 1 2
ACUTE REHAB ▪ Typical Length of Stay: 10-14 days ▪ Patient needs therapy in two areas (Physical, Occupational, or Speech) ▪ Must be able to participate in therapy for 3 hours a day ▪ Medicaid patients are required to go to “Freestanding Facilities”
ACUTE REHABS ▪ Baptist Rehab Institute (BRI), LR—Freestanding ▪ liaison Kellye Tucker P: 501-352-7595—Has epic access, in basket facesheet & overview ▪ Has Spinal Cord & Traumatic Brain Injury (TBI) Programs ▪ Baptist Springhill, NLR & Baptist Conway ▪ Liaison Abby P: 501-680-0974 ▪ Encompass Sherwood (formerly CHI/St Vincents)—Freestanding ▪ Liaison Sheila P: 501-351-9530 ▪ Tend to accept lower level acute rehab patients ▪ Encompass Hot Springs ▪ Liaison Veronica P: 501-547-0823 ▪ Kindred Rehabs (JRMC-Pine Bluff, Saline Memorial-Benton, National Park-Hot Spings, St Mary’s-Russellville, White River-Batesville) ▪ Liaison Kim Terry P: 479-223-7579 ▪ No wheelchair van transport offered ▪ Conway Regional Inpatient Rehab, Conway—Freestanding ▪ Liaison Debbie P: 501-472-7464, has epic access—just needs facesheet
SUBACUTE REHAB ▪ Typical Length of Stay: 21 Days ▪ Patient needs therapy in one area (Physical, Occupational, or Speech) ▪ Medicaid does not provide coverage ▪ Located within a nursing home ▪ If payor is Medicare: Patient must have 3 inpatient midnights within past 30 days. ***If a third party biller is involved (MVA-vehicle insurance), and the other person is at fault, placement can be difficult. Will need police reports and insurance policy information***
ACO ▪ Accountable Care Organization ▪ Group of doctors, hospitals, and other providers who come together and voluntarily give coordinated high-quality care (CMS, 2021). ▪ Patients enrolled will have ACO Banner ▪ To be enrolled, patients must receive majority of their care from Baptist or UAMS ▪ Successful ACOs deliver high quality care and spend health care money wisely. Pro Tip: ACO patients do not require 3 inpatient midnights for SNF admission. They must go to a 3 star facility
SUBACUTE REHAB LIAISONS ▪ Tammy Collins ▪ Phone Number: 501-545-1904 ▪ Fax Number: 866-480-9518 ▪ Claudia Sanders ▪ Phone Number: 501-231-9479 ▪ Fax Number: 501-325-1108 ▪ Ashlee Hiebert ▪ Phone Number: 501-416-0960 ▪ Fax Number: 501-325-2086 ▪ Joanna with The Blossoms Facilities ▪ Phone Number: 501-628-4523 ▪ Dana with The Springs Facilities ▪ Phone Number: 870-224-6507
BUNDLED PAYMENT FOR CARE IMPROVEMENT (BPCI) • UAMS participates in 12 different bundles (DRG driven) • Each “episode” is 90 days • Donna Malone is BPCI-A Transitions of Care RN CM • Phone: 501-265-9581
BOCK/PASSR ▪ Pre-Admission Screening Resident Review ▪ Federally mandated process ▪ Determines if an individual meets nursing facility level of care
▪ Grace Ann is hospital rep, P: 501-269-0145 ▪ Home Wound Vacs ▪ Order form is located in the Box, attending signature required ▪ Will be delivered to hospital & applied prior to DC ▪ Facility Wound Vacs ▪ They are responsible for acquiring ▪ Will need arrangements made for dressing changes (home health, clinic, etc) ▪ Never send a UAMS wound vac to another facility ▪ Wound vac sponge can be in place for 2 hours without suction ▪ May need wet to dry dressing if commute is greater than 2 hours
▪ Skilled Nursing (SN), Physical Therapy (PT), & Speech Therapy (ST) can all “stand alone” ▪ OT & Aide must be paired with either PT or SN ▪ Patient doesn’t have to be seen by PT/OT/ST to qualify for home health services. Eval can be completed by home health staff ▪ Avant Garde is preferred ▪ If patient had home health prior to admission ▪ Observation—no new order needed, just send DC summary & notify HH company ▪ Inpatient—new order needed, may say “resume all previous home health orders” if nothing needs to change ▪ Out of State patients ▪ HH orders can only be written by physicians in the state the patient lives ▪ Have their PCP write orders for HH
▪ Identify a Teachable Caregiver. ▪ Select Home Health Company. ▪ If unable to secure home health company, options are as follows: ▪ UAMS Regional Clinics ▪ Helena ▪ Jonesboro ▪ Fayetteville ▪ Batesville ▪ Magnolia ▪ Texarkana ▪ Pine Bluff ▪ Fort Smith ▪ Reach out to patient’s PCP to see if able to schedule labs & PICC dressing changes in their clinic ▪ UAMS infusion & Lab if local patient ▪ This is a last resort option ▪ Email Infusion 1 Scheduling & cc Infusion 1 RN. Include treatment plan and ask they schedule patient for weekly dressing changes and labs. The team will have to put in an order, if they don’t know how…they need to reach out to the help desk
▪ If uninsured can obtain DME at ICAN, goodwill, churches, etc ▪ Must have valid Arkansas Drivers License for ICAN ▪ The Cure (Northwest Arkansas) ▪ Matt: 479-883-4096 ▪ Ron: 479-650-9666
▪ Send early home health referral. ▪ Don’t wait for orders! Let them know, once we have our final ID recommendations, we will send orders. ▪ They can run benefits and ensure patient won’t have large out of pocket costs for home health. ▪ Select Infusion Company. ▪ Red River, OptionCare, Vital Care ▪ Send referrals early! ▪ Again, this allows the company to run insurance benefits to see what kind of out of pocket cost patient will need to anticipate. ▪ Once final treatment plan is entered, and DC Home IV order set has been completed fax referrals to both home health and infusion ▪ Be sure there are plans for how to have patient’s PICC pulled ▪ Out of State infusion ▪ Ask your infusion company if they have out of state branches or can coordinate delivery
▪ Required for hospital & LTACH transports ▪ Can be set up for all other discharges if patient qualifies ▪ Required to arrange through MEMS ▪ MEMS will outsource if unable to provide transportation services ▪ Will need to submit PCS form and contact dispatch ▪ If primary payor is Medicaid, physician will have to sign ▪ DNR patients will need either POLST or MEMS DNR form (located in box) ▪ MEMs will ask for up front payment for transport services not covered by insurance ▪ Some patients & facilities have contracts with ambulance services, let dispatch know
▪ Patient is medically ready to discharge, but there is something preventing that from occurring ▪ Entered by Kimberly Colbert, UR RN ▪ Tracked to trend internal/external barriers
▪ Notaries available by emailing [email protected] ▪ We can only provide information to patients regarding disability applications, we don’t apply on their behalf ▪ Undocumented citizens can apply for Emergency Medicaid (only covers one hospitalization, and no discharge coverage) ▪ UAMS NPI # 1477549756; UAMS Tax ID #716046242 ▪ Provider NPI look-up: http://echo.uams.edu/echonet/payerportal/drsearch.asp
▪ Davita Dialysis Rep: Ashley 866-475-7757 ext. 253203 ▪ UAMS 12th Street Health Wellness Clinic (Free) ▪ 4010 W 12th Street ▪ 501-614-2492 ▪ Open Monday (1600-2000), Wednesday (1600-2000), & Thursday (1600-1800) ▪ AR Connect—24/7 virtual mental health and substance abuse program ▪ 501-526-3563 or 800-482-9921