by Jackie Birmingham, RN, MS
The transition-management strategies used in inpatient settings should be applied in outpatient settings as well. That’s because more patients with more complex needs are being treated as outpatients, and they have continuing care needs – especially those who are self-managed and at greater risk for preventable outpatient failure.
There are also financial reasons to pay more attention to patient transitions from outpatient services. The so-called three-day payment window rule from the Centers for Medicare and Medicaid Services (CMS) bundles diagnostic and non-diagnostic services with a related inpatient admission. Evolving models such as Developing Outpatient Therapy Payment Alternatives (DOTPA), the Post-Acute Care (PAC) Payment program, and Accountable Care Organizations (ACO) pilot programs all link patient treatment with outcomes.
The Same Process, with a Difference.
As with discharge planning for inpatients, transition management for outpatients should identify those patients who will need services; assess their ongoing needs; find appropriate resources; and then match, plan and implement. What is different with outpatients is how they interact with staff focused on services like PT, OT, infusion or diagnostic tests. It’s vital to anticipate and tee up the resources patients may need to stay out of the hospital.
That requires appropriate staffing: case managers, social workers, clinical nurse specialists or nurse practitioners, who, in addition to assessing clinical needs, must review patient living status. Outpatient therapy is not a stress-free event. Staff must assess each patient’s (or caregiver’s) ability, availability and willingness to manage medical needs and activities of daily living. For a patient at risk for an inpatient admission because of trouble taking care of himself, the physician and staff should consider a home-care referral as part of outpatient services. Complementary community-based services may also help avert an inpatient admission. Easy, reliable access to those providers is important, especially given the short time the patient is in the outpatient setting.
Another key to transitions with successful outcomes is data. It’s critical to track inpatient admissions from outpatient services as well as the converse, outpatient admissions from inpatient settings. Collecting and tracking data on the reasons for admissions may reveal patterns of practice or work flow that can be improved through quality measures, risk management or technology.
With a sharper focus on outpatient transition management, you can expect to admit fewer inpatients. With better data about the transitions of patients who do require admission, you’ll have the documentation to justify medical necessity by showing that no other option was appropriate. You’ll also have better documentation for claims processing and appeals to auditors. And, last but not least, you can expect to improve patient satisfaction by providing more coordinated care.
Jackie Birmingham, RN, MS, is vice president of regulatory monitoring and clinical leadership at Curaspan Health Group.
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Related Link:
Six Ways to Use Communication for Good Patient Transitions
