By Tiffany Ferguson, LMSW, CMAC, ACM

Maybe there is a greater understanding of patients’ understanding their Medicare appeal rights or maybe there is a growing occurrence of patients feeling like they are leaving too quickly from the hospital without a solid plan in place. Regardless of the cause, we are seeing an increase in hospitals and health systems where patients take full advantage of their Important Message from Medicare (IMM) and appeal their discharge to the Quality Improvement Organization (QIO).

I recently received a document for review from a health system that wanted to implement a policy for “patients who refuse to leave.” I had to question what this was really trying to achieve.  Is the policy for the patient or for the hospital?  I questioned if a written document was really going to get the patient out the door. If the patient refused to leave, the answer seemed to be “make their lives miserable so they will concede with our ‘safe discharge plan.’ Upon further investigation, conversations grew regarding the ongoing frustrations the case management, leadership team and the physician advisors had with patients who were treating the hospital like a place of residence.  I sympathized with the growing frustration and the burden this places on the care team; however, I informed them that forcing the patient out the door will also lead to greater patient disdain and the likelihood of a very burdensome process if the patients appeal their discharge.

It is understandable that hospitals will see socially complex patients, and unfortunately, I do not see this problem going away anytime soon.  If socially complex patients had the means to address their issues in an outpatient or community setting, they would have.  The subsequent hospitalization is because the patients have failed to plan or are unprepared for the plans that now arise in the need to show up to the emergency room and will likely delay any coordination of efforts when it is time for discharge. If we understand the reality that some of our patients have significantly neglected their health either consciously or because of their social determinants, we can come to a better framework to work with them.

When we see a patient appeal their discharge or refuse to leave, it is likely because of an unmet need or fear of an unmet need. The patient may fear returning home so soon after previously failed attempts. Their appeal is often a sign that the patient’s requests are not in line with the care team’s plan.  This absolutely happens, but in a proactive case management program, this should be rare. What I often see in greater frequency with hospitals when this issue arises is a care team that has worked around the patient to put together the discharge plan and then has told the patient the plan after recommendations are made. This likely occurs because case management and hospitalists feel rushed and overwhelmed and then surprise, the patient feels left out and executes their rights that the hospital team has told them about several times throughout the hospitalization that they are allowed to do, via a written signed notice, the IMM. This results in more work as the care team must ”stop the line” and rework everything or execute the appeal process, which involves a lot of people, time and effort. This whole process puts staff farther behind and feeling more overwhelmed. This is all reactive!

A good initial assessment with the patient who is collaborative, rather than a mechanism for data collection of what nursing already has collected or is already in the EMR, can solve a lot of these issues. During the process of formulating a transition plan with the patient, it will be helpful to keep them included and ensure they understand and are comfortable with the terms the care team is using. Patients may not understand the difference between a skilled nursing facility and a nursing home.  They may be unsure about what their insurance covers or may be unable to pay for the out-of-pocket costs. They may have limited family support and struggle with coordinating outpatient support to facilitate an arrival back into their home.  Caregivers may be feeling burnout and struggling with the thought of bringing their loved one back into the house. The goal is to be advocating on behalf of our patients with a proactive approach to identify barriers and facilitate the progression of care and transitions needed for discharge. This requires case management to take the needed time up front to listen to the verbal and non-verbal cues their patients are telling them to collaboratively transition the patient out of the hospital and into the next care setting or home environment.

Bio: Tiffany Ferguson is CEO of Phoenix Medical Management, Inc., the case management company. Tiffany serves is an adjunct professor at Northern Arizona University, Department of Social Work and on the American College of Physician Advisors (ACPA) Observation Subcommittee. Tiffany is a regular contributor to RACmonitor, Case Management Monthly, serves on the editorial board for CMSA Today, and commentator for Finally Friday. She is a weekly correspondent on SDoH for the news podcast, Monitor Monday. 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 in Health & Care Management, which includes CM, UR, CDI, HIM, and coding. She has held c-level responsibility for a large employed medical group which included value-based arrangements, PCMH, and outpatient care management. Tiffany is a graduate of Northern Arizona University and received her MSW at UCLA. She is a licensed social worker, ACM, and CMAC certified.

Interested in learning more about the complexities of patient discharge? CMSA’s ICM program provides multiple strategies to engage clients, stratify risk, and develop care plans to mitigate risk and help clients achieve improved health and well-being. Join the Spring ICM training, April 4-6: A virtual face-to-face training. Addressing the whole person and their physical, behavioral, and social health and needs is essential for positive health outcomes and cost-effective care. This course will provide out-of-box strategies to reduce the risks contributing to complexity. Register now: