Master the upcoming ICD-10 code and IPPS changes! Prepare your team for the upcoming changes taking effect on October 1. Discover the benefits of IPPSPalooza and how it can drive your success. Click here >

When Did the Hospital Become a Pathway to Housing?

When Did the Hospital Become a Pathway to Housing?

In my recent hospital travels, involving working with frontline case management staff, we completed an initial assessment and intervened with a patient who provides one example of the significant issues hospitals are seeing when it comes to social admissions. The patient was a 47-year-old quadriplegic male admitted with back pain. The patient had a significant trauma approximately five years ago from a diving incident that completely turned his life upside down and landed him dependent on family and governmental support.

The patient was admitted to the hospital under outpatient with observation services while his “back pain” was being evaluated. In reviewing the hospitalist history and physical examination (H&P) we learned that the patient was “hoping to go to skilled care until he could move into his brother’s house.” This is a red flag, from a case management standpoint, and warranted further investigation with the patient. 

During our conversation with this likable gentleman, we saw his predicament: his one brother, who is a paid caregiver, can no longer easily care for him due to his own age and debility. The patient’s other brother is now willing to take him in and care for him, but his home will need significant remodeling to handle the patient’s handicap needs. The patient believed that if he “got into the hospital,” he could either get greater caregiver support or go to skilled nursing while the home repairs were completed. When asking the patient why he believed the hospital would solve this problem, he stated that this is what he remembered his previous rehab physician telling him. 

This is one example of the systemic issues in our communities: there is a failure to intervene with patients, resulting in an unnecessary hospitalization, meaning that their social determinant, most often housing, can be solved in the hospital. Patients are sitting in beds in hospitals across the country, as we speak, because they are homeless and lack access to supportive shelters, because their home situation is inadequate, or because they require a pathway to long-term nursing care facilities. Time and time again, the hospital has become the answer to these determinants, rather than the community-based social services. 

Physicians’ heartstrings are being pulled with patients being admitted to the hospital, because their social situation is “not safe,” skewing the boundaries and definitions of medical necessity. This is by far the most expensive means to a necessary result to help these individuals, and unfortunately, the payor system does not support the need. In our fee-for-service world, this patient scenario will likely result in denied days for observation from his managed Medicaid plan. The hospital case manager and physician will then deal with the ethical dilemma of discharging this patient and many others back to their subpar conditions. 

This patient does not belong in a skilled nursing facility (SNF), nor does he have medical necessity for such placement. The easy answer would be to try anyways, but instead, the case manager and I spun our wheels trying to creatively find social-service and volunteer agencies to help this patient, while also trying to find his long-term care case manager. Our efforts were an attempt to get his caregiver hours increased and educate the patient on the realities of his health insurance and unnecessary hospitalization. 

This topic will continue to be an area of conversation by MedLearn Media, with Dr. Hirsch’s upcoming webcast regarding payment and compliance for the “Outpatient in a Bed” designation, as well as future webcast topics focusing on social complexities and methods for hospitals to handle such patients.

The initial answer involves figuring out how we can prevent the regular response of “go to the hospital” – and if the patient arrives nonetheless, how we delineate social complexities with unideal determinants from medical necessity.

Programming note: Listen to Tiffany Ferguson’s live reporting on the social determinants of health (SDoH) today on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer, 10 Eastern.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn
Email
Print

Tiffany Ferguson, LMSW, CMAC, ACM

Tiffany Ferguson is CEO of Phoenix Medical Management, Inc., the care management company. Tiffany serves on the ACPA Observation Subcommittee. Tiffany is a contributor to RACmonitor, Case Management Monthly, and commentator for Finally Friday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles for Health and Care Management and c-level responsibility for a large employed medical group. Tiffany received her MSW at UCLA. She is a licensed social worker, ACM, and CMAC certified.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.

Print Friendly, PDF & Email
September 19, 2023
Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Explore comprehensive guidelines and best practices for secondary diagnosis coding in our illuminating webcast. Delve into the intricacies of accurately assigning secondary diagnosis codes to ensure precise medical documentation. Learn how to navigate complex scenarios and adhere to coding regulations while enhancing coding proficiency. Our expert-led webcast covers essential insights, including documentation requirements, sequencing strategies, and industry updates. Elevate your coding skills and stay current with the latest coding advancements so you can determine the correct DRG assignment to optimize reimbursement, support medical decision-making, and maintain compliance.

Print Friendly, PDF & Email
September 20, 2023
Principal Diagnosis Coding: Mastering Selection and Sequencing

Principal Diagnosis Coding: Mastering Selection and Sequencing

Enhance your inpatient coding precision and revenue with Principal Diagnosis Coding: Mastering Selection and Sequencing. Join our expert-led webcast to conquer the challenges of principal diagnosis selection and sequencing. We’ll decode the intricacies of ICD-10-CM guidelines, equipping you with a clear grasp of the rules and the official UHDDS principal diagnosis definition. Uncover the crucial role of coding conventions, master the sequencing of related conditions, and confidently tackle cases with equally valid principal diagnoses.

Print Friendly, PDF & Email
September 14, 2023
2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY24 Inpatient Prospective Payment System (IPPS) Final Rule, including new ICD-10-CM/PCS codes, plus insights, analysis and answers to questions from the country’s most respected subject matter experts.

Print Friendly, PDF & Email
2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

This third session in our 2024 IPPS Summit will feature a review of FY24 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from two acclaimed subject matter experts

Print Friendly, PDF & Email
August 17, 2023

Trending News