Given the current healthcare climate, hospitals have become the backup plan for many social problems for which there is not a viable solution.
Many patients with chronic health problems have insufficient family or community support, and in addition to an overall shortage of nursing-home beds, many patients are unable to afford nursing home care, as they have too many assets to qualify for Medicaid, but not enough to afford the cost of custodial care.
This leaves providers in the unenviable position of caring for the most vulnerable patients, who may be medically stable, but are not safe for discharge. Patients are brought to the hospital, sometimes for legitimate medical concerns, and sometimes simply because their family is exhausted by their custodial care needs and can no longer care for them at home.
Once the initial medical evaluation is complete, the patient is often found to be medically stable, but not safe for discharge back to their prior living arrangement – or they require additional workup for a chronic issue, which could be performed in the outpatient setting, but due to the living situation, homeless status, or lack of transportation, the attending finds that the safest course of action is to hold them in the hospital to complete a diagnostic review.
Our first commitment is always to protect our patients’ safety, so these holds are often the most appropriate and ethical course of action.
So, what are we to do from a case management perspective?
As a long-term strategy, working collaboratively with local entities such as homeless shelters, public housing agencies, nursing homes, and public transit authorities who assist with disabled travelers can lead to the formation of alternative pathways to ensure that patients are kept safe, but can be transitioned to another level of care outside the hospital setting. Creating relationships with local pharmacies and durable medical goods providers can help with timely discharge that is sometimes delayed simply because it’s the weekend, when both medication and durable medical equipment are harder to acquire.
If the patient needs to be held beyond continued medical acuity or without intensity of care that would support an inpatient order and they cannot safely be discharged, we should leave the patient in an outpatient status.
Simply changing them to inpatient status based on their length of stay will not hold up with Medicare fee-for-service (FFS) or commercial carriers, who look at both medical acuity and intensity of care to define an inpatient level of care.
Maintaining an outpatient level of care will allow you to bill for medications administered and diagnostic procedures performed, but not for room and board.
While reimbursement will not be as much as for an inpatient admission, you will be adhering to a compliant status and preventing the dreaded audit and subsequent repayment of your reimbursement. You will also avoid being labeled as a facility with behavior creating suspicions of fraud and abuse.
While this does not have a short-term financial benefit, the long-term benefits are priceless!