There is no Magic Wand!

FIVE WEEKS LATER…

It has been five weeks since the White House announced a series of regulatory waivers designed to help providers and states in responding to the spread of COVID-19 under Section 1135 of the Social Security Act. 

Section 1135 waivers are intended to ensure that enough healthcare items and services are available to meet the needs of individuals enrolled in Medicare, Medicaid, CHIP, and other healthcare programs and that providers who provide such services in good faith can be reimbursed and exempted from sanctions unless there is evidence of fraud or abuse. (ASTHO, 2020)

Since that time, health care systems have used this flexibility to respond to the evolving health care crises caused by COVID-19.

Make them disappear!

Like the magicians of old, we are being asked to make patients “disappear” from acute care more quickly.  The 1135 waiver helps, as CMS waived the three-day hospitalization rule to cover a skilled nursing facility (SNF) under Medicare.  Theoretically, this would enable us to send discharge ready patients to SNFs more quickly and admit acutely ill COVID-19 patients. 

However, there is no magic here, and recent news reports of high numbers of infected persons in SNFs around the country are likely an impediment to this quick turnaround.

SNFs are facing their own challenges in protecting their patients and staff from COVID-19 and require support providers to take on this additional responsibility (Buys, 2020).

SNFs are concerned at the idea of taking on patients who may have COVID-19 infections. (Graham, 2020).  After all, we have all heard of the facility in Kirkland, Washington that experienced the first “hot spot” in a long-term care setting, which resulted in at least 37 deaths.  As of April 18, 2020, there were 7300 COVID-19 deaths in SNFs reported nationwide. (ABCNEWS, 2020).

The American Health Care Association (AHCA), an industry organization recommended on March 30th, that SNFs could accept known negative, or asymptomatic patients, and went further to state if someone has symptoms such as a dry cough or fever, they “should be tested for COVID-19 before being admitted to the facility.” If someone is COVID-19 positive, they should be kept only “with other COVID positive residents.” However, these recommendations are being met with pushback in certain areas (Graham, 2020).

Where are patients to go? 

The answers to these questions vary from state to state.  In NY, for example, beds were made available at the Javits Convention Center to manage the care of COVID-19 patients, discharged from acute care, but in need of continuing care. Other municipalities have expanded care into hotels, gymnasiums, and other large sites, to decompress the acute care hospitals. (Graham, 2020).  In the absence of such alternatives, the question remains, “where do the patients go?”

So, what is a Case Manager to do? 

If there were a magic wand, it would be easy, but case managers, even in the most difficult of times, are charged with providing safe transitions of care, and the Case Management standards of practice (CMSA, 2016) include advocacy for the patient and financial stewardship (Miondonski, 2012).  Chapter VIII, Section N of The Standards of Practice for Case Management (CMSA, 2016) state: “The professional case manager should integrate factors related to quality, safety, access, and cost-effectiveness in assessing, planning, implementing, and evaluating health resources for client care.”

Carolyn Buys (2020), writer for the Advisory Board, interviewed leadership at the UW Medicine in Seattle, WA to get insight as to how best to accomplish discharge planning in these trying times. 

Among the recommendations were the following:

• HOME first.  On considering discharge plans, the home should be number one. This might be a better option for our frail patients than SNF, and, as most families are home due to “stay-at-home” rules, easier to facilitate.  If the discharged patient is positive for Coronavirus, then this prevents spread within an SNF.  If they are not, it helps prevent their acquiring it.
   
• Set expectations of post-acute providers.  Clear communication with providers is the key to success. Emphasize what you and your organization CAN do to facilitate a safe transition, rather than what you can’t.
   
• Engage in regular conversation with your post-acute partners.  Ask:
  • What are the current admission requirements/restrictions?
    • What can be done to address them?
  • What information, above and beyond the usual, do they need about the potential patient?
  • What support can you provide for them to expedite a transition?
  • What is the bed capacity for COVID-19 positive/negative patients?
    • How many beds are available? (Ask this every day!)

So, you see, there may not be a magic wand. But there are certainly things we as case managers can do to provide the safest possible discharge plans for our patients in this unprecedented health care crisis. 

References

ABC News, (2020).  At least 7,300 deaths confirmed at nursing homes around the nation.  Accessed April 20, 2020 from:  https://abcnews.go.com/WNT/video/7300-deaths-confirmed-nursing-homes-nation-70227436

ASTHO, (2020).  Emergency Authority and Immunity Toolkit. Robert T. Stafford disaster relief and emergency assistance fact sheet.  Accessed April 14, 2020 from:  https://www.astho.org/Programs/Preparedness/Public-Health-Emergency-Law/Emergency-Authority-and-Immunity-Toolkit/Robert-T--Stafford-Disaster-Relief-and-Emergency-Assistance-Act-Fact-Sheet/

Buys, C. (2020). 7 lessons on discharge planning during COVID-19 from UW Medicine.  Accessed April, 20, 2020 from:  https://www.advisory.com/daily-briefing/2020/04/03/uw-medicine

Graham, J. (2020).  Coronavirus patients caught in conflict between hospital and nursing homes.  Accessed April 20, 2020 from:  https://khn.org/news/coronavirus-patients-caught-in-conflict-between-hospital-and-nursing-homes/

McGuire/Woods.com.  (2020).  CMS responds to COVID-19 emergency declaration.  Accesed April 13, 2020 from: https://www.mcguirewoods.com/client-resources/Alerts/2020/3/cms-responds-to-covid-19-national-emergency-declaration

Miodonski, K. (2012).  Aligning Case Management Processes with the Revenue Cycle. Becker’s Hospital CFO Report.  6/8/2012.  Accessed from  https://beckershospitalreview.com/finance/aligning-case-management-processes-with-the-revenue-cycle.html