Scenario
Transitional Care is a moderate to long term facility that focuses on therapy, wound care, and medical management of chronic diseases. Individuals within transitional care can range from low need or minimal care to individuals who are total care patients need 24 hour nursing assistance. These facilities are often known as Long Term Care, Skilled Nursing Facility or Subacute Rehab.
Patients who do not return home directly from the hospital are transferred to a lower level of care. Transitional care can take place in many different types of health care settings, such as a skilled nursing facility, long-term care facility, or subacute unit specializing in rehabilitation therapy, wound care, IV therapy, and/ or post acute cardiac care. There are various staff arrangements based on the focus of care, but generally there is a registered nurse (RN) in charge, who may only work the day shift with the assistance of licensed practical nurses (LPNs) and certified nursing assistants (CNAs), and a medical director who may visit the facility daily (or 2-3 days per week) but who is on call for emergencies. This specific transitional care unit consists of a 35-bed unit located within a 300-bed skilled nursing facility and is generally close to the patient’s home. There are RNs (staff) on duty 24/7 with a physician or nurse practitioner 7 days per week. The facility is a nonprofit, community-affiliated organization with a community board of directors that oversees the operations of the facility. The facility has a strong history of delivering quality services and high patient satisfaction. The facility is known for the implementation of the latest electronic medical record (EMR) technology. It has a five-star rating from the Department of Health and Commission on Medicare and Medicaid (CMS) with The Joint Commission Certification. You have just been notified of a situation that has occurred in the facility. A patient was admitted to the transitional care unit and was assessed by both nursing staff and physical therapy staff in order to develop a plan of care for the patient to return home. It was initially anticipated that following IV therapy the patient would be discharged home in 5 days (this is the standard stay, including the staffing ratios, in the operational budget). However, the patient developed an infection and has to have an additional 6 days of antibiotic fluids, which increases his stay from 5 to 11 days. As the administrator, you now need to evaluate the financial impact to your organization, keeping in mind that the insurance is only paying 50% of the IV therapy and only 35% of the extension of stay beyond the original authorization.
A) What is the financial impact of this situation on the organization? Develop a short plan for how you would compensate for this situation.
B) What is the importance of an administrator understanding how private and government payers impact actual reimbursement (payment for services and methods of payment). From the perspective of an administrator in this scenario, why would monitoring reimbursement be so critical?
C) Is there a possibility of patient litigation surrounding this issue? How would you handle this situation?