critical access hospital swing bed program cah/march 1...critical access hospital swing bed program...
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CRITICAL ACCESS HOSPITALSWING BED PROGRAM
Operational and Management Strategies
Suzy Harvey, RN-BC, RAC-CTManaging Consultant
[email protected] Elliott, CPA
Senior Managing [email protected]
March 1, 2016
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Agenda• Coverage Criteria• Swing Bed Management & Utilization• Important items for SB Cost Reports• CAH Financial Ratios• CCJR• Questions
Skilled Nursing Facility vs CAH Swing Bed
Level of Care
Level of Care
• Swing beds must meet same level of care criteria as Skilled Nursing Facilities
SB SNF
Operational Benefits
• Provides viable option to local community• Increased in-house services for the community• Physicians can easily monitor their patients without
moving them• Keeps patients in the community• Helps to manage Nursing hours with less drastic
fluctuation in the census• Cost-based reimbursement • No length of stay requirements
Patient Benefits of Swing Bed
• Improved Patient Care• Opportunity to identify patient needs to assure
safe and sustainable return home• More time for training, demonstration, return
demonstration, education to patients and family• Extra time to put post-acute discharge plan in
place• Increased patient/family satisfaction (“not thrown
out”)• Willingness to go to a skilled level of care while
meeting their needs for a longer inpatient stay
Resources
• The policies for extended care services in a Swing-Bed are the same as a SNF.
• Medicare General Information, Eligibility and Entitlement Manuals– Chapter 3, Section 10.4– Chapter 4, Section 40
• Medicare Benefit Policy Manual– Chapter 8, Sections 10,20,& 30– Chapter 15, Section 220
• State Operations Manual– Appendix W
Coverage Criteria
Technical Eligibility
• Medicare Part A available days• Medicare Advantage Plan or Managed Care • Three consecutive day qualifying stay in acute
hospital (3 midnights) within the last 30 days• 30 day Transfer Rule
– Medically appropriate exception
• Physician Certification
Clinical Eligibility
• Skilled Services performed or supervised by a qualified technical or professional health personnel
• For a condition, which arose while receiving care for a conditions for which he received inpatient hospital services
• Services required Daily– Skilled Nursing Services 7 X week– Skilled Rehabilitation Services at least 5 X week
• Reasonable and necessary
Skilled Services Defined
• Nursing or Therapy services– Furnished per physician order– Require skills an d qualification of professional
personnel– Provided directly by or under supervision of skilled
personnel
Determining Skilled Services
• Skilled level of care is usually required because of the patient’s condition, which may:– Be unstable– Require complex treatment– Be associated with multiple unskilled problems
which demand professional management– Be a chronic situation that confines the patient and
requires ongoing nursing decisions about services on a daily basis or
– Terminal, meeting the requirements of skilled care.
Nursing Services - Skilled
• Direct Skilled Nursing Services• Care Plan Management• Observation and Assessment• Teaching and Training
Questionable Situations
• Situations that do not support evidence of daily skilled service– Primary services needed is oral medications– Patient is capable of independent ambulation,
dressing, feeding and hygiene– Therapy for strength and endurance– Passive ROM
Swing Bed Management & Utilization
Inquiry/Initial Pre-Assessment Process
• Process should begin day 1 of acute hospital stay.• Hospital discharge planner, along with UR committee,
review all acute patients-daily• Identify patients eligible for SB• Notify Physician of SB eligibility• Notify Patient or Representative
Patients in ER/Observation
• Utilizing the 30 Day Transfer Rule• Has the patient been in the hospital or received
skilled care in the past 30 days?• Is the reason for ER/Observation related to the
most recent hospital stay?
• Admit to Swing Bed
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Swing Bed Tracking Form
• Recommend use of;– Tracking form
• Good way to determine type of patients not being admitted
• Great for marketing
– Pre-screening form• Examples of both included in handout
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Utilization Review
• Manage care needs• Ensure stability prior to discharge• Monitoring acute stay for 96 hour
requirement or GMLOS of diagnosis• Look at length of stay
– Typically less than 5 days– Increase to 7-10 days for safe and sustainable
discharge
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Summary
• Risk management is essential for effective utilization of Swing Beds– Verify all eligibility criteria is met– Documentation to Support Skilled Care– Manage the patient stay– Ensure safe and sustainable discharge– Increase length of stay as appropriate to prevent
rehospitalizations
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Swing Bed Financial Implications
CAH Cost Report Important Items
• Importance of reporting correct patient days:• CAH cost per day • Observation days (typically calculated based upon
hours patient is in observation) must be correct to allocate costs for this service – outpatient service
• Report Medicare HMO days (Acute Part C) to increase Medicare utilization for EHR payments
CAH Cost Report Important Items
• Importance of reporting correct patient days:• Should also segregate Medicaid HMO days from
straight Medicaid for those receiving Medicaid DSH (for tie out to audits by the state)
• Exclude days related to self-insured insurance plan• NF days paid consistent with Medicare rates
should be included on the SNF line
CAH Cost Report Important Items
• Importance of reporting correct patient discharges:• Discharges must be correct for CAH average length
of stay calculations• Plan to track hours patients are in-house as acute,
if length of stay is approaching 96 hours• EHR importance for Medicaid
CAH Cost Report Important Items
• Reporting correct days example:
Routine cost $ 984,560
Routine days total 1,075(error of 10 days)
Cost per day $ 915.87
CAH Cost Report Important Items
• Reporting correct days example:
Routine cost $ 984,560
Routine days total 1,065(correct days)
Cost per day $ 924.47
CAH Cost Report Important Items
• Reporting correct days example:• Routine cost per day (correct) $924.47• Routine cost per day (error of 10 days) $915.87• Error per day $8.60• Medicare acute/swing bed days 635• Reimbursement impact $5,461
CAH Cost Report Important Items
• Accurate matching revenue and expense• Revenues and expenses should be properly
matched on the cost report (line numbers)• Proper and consistent cut-off of both revenue and
expenses for your year-end• Following asset capitalization policy for new assets
and repairs
CAH Cost Report Important Items
• Physicians• Important to be proactive to correctly capture all
physician costs for the cost report.ER availability – time studies (write into contract
that this is a requirement)Medical Director – time studies or contract
languageER Call Pay – contract language and time study
CAH Cost Report Important Items
• Statistics• B part I is a summary of all costs as allocated by
the B-1 statistics.• The data can be used for more than just the cost
report.• Review these allocations for changes from year to
year and also what is going to non-reimbursable cost centers.
CAH Financial Ratios
• What is your total occupancy rate?• What is your length of stay?• What is your swing bed length of stay?• What is your opportunity?
CAH Financial Review
CAH Financial Review
CAH Financial Review
CAH Financial Ratios
• Occupancy rate (4,021/9,125) 44.1%• Length of stay (4,021/1,018) 3.95• Swing bed length of stay (557/93) 5.99• Medicare Percentage (2,311/4,021) 57.5%• There appears opportunity to increase patient
utilization of the swing beds, as many SNF providers see ALOS of 10-14 days. If could add 4 days to LOS would result in 372 additional days.
CAH Financial Revised Ratios
• Occupancy rate (4,393/9,125) 48.1%• Length of stay (4,393/1,018) 4.32• Swing bed length of stay (929/93) 9.99• Medicare Percentage (2,683/4,393) 61.1%
CAH Financial Results
Medicare Days
Medicare Discharges
Medicare ALOS
Total Days Medicare Days
Medicare Discharges
Medicare ALOS
Total Days
Acute/ICU 1,754 483 3.63 3,464 1,754 483 3.63 3,464 Swing Bed - SNF 557 93 5.99 557 929 93 10 929 Swing Bed - NF - - - - Observation - 528 - 528 Total Days 2,311 4,549 2,683 4,921
Total Routine Cost 4,879,006 4,879,006 Less: Swing Bed - NF Costs - - Adjusted Total Routine Cost 4,879,006 4,879,006 Total Days (Less Swing Bed - NF) 4,549 4,921 Total Routine Cost Per Day 1,072.54 991.45 Medicare Days 2,311 2,683 Medicare Acute & Swing Bed SNF Cost 2,478,651 2,660,136
Medicare Routine Cost Reimbursement % 51% 55%
181,485
Comprehensive Care for Joint Replacement (CCJR)
• CAH’s are not subject to CCJR HOWEVER• CAH’s in CCJR MSA’s should not expect
admissions into their swing beds from other acute hospitals based on the high cost of service (as compared to skilled nursing facilities and home health agencies)
• CAH’s should monitor legislation as other MSA’s and other DRG’s are added which could impact referral sources
Summary
• Cost report is important for more than just the settlement
• Provides important management information• It is important that the individuals involved in
preparing the cost report understand the importance of all the issues surrounding CAH reimbursement
• Monitor CAH reimbursement on an interim basis to avoid significant under/over payments at year end
QUESTIONS?
