1. Powell, Suzanne K. MBA, RN, CCM, CPHQ

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Recently, I have had the interesting experience of being at the "other" end of Medicare appeals. In the past, I related to the case manager in a hospital, skilled nursing facility, or home health agency who gave patients the "Important Message from Medicare," which explained their Medicare rights and how to appeal a discharge to which they disagreed. This time I was on the receiving end of the calls from Medicare beneficiaries who felt they were being discharged from the facilities before they were ready. Essentially, I was assigned two functions: one was speaking to the beneficiaries about their perceptions of what was happening and, Second, once the medical records were obtained, I assembled the records for the physician reviewer.


In the first job, the beneficiaries or their families lamented an entire range of frustrations, from having no notice that discharge was imminent to being totally unprepared for the transition. Having been on both sides of the case management road, I do know that the truth is usually somewhere in the middle. Some families and beneficiaries probably were not prepared adequately for the discharge, whereas others (for a variety of reasons) could not grasp all that was being said and done to prepare them. It also became more apparent than ever that a whole range of people call themselves "case managers" with little resemblance to how I know our case management readers provide service.


That being said, once the medical record arrived, I often found little evidence that adequate transition planning had been done. Patients who should have been evaluated for long-term care because of major life changes or deterioration of a current ability to care for oneself were not assessed in the hospital level of care or the skilled nursing level of care. In general, few records documented adequate discharge planning. To be sure, I called the "case manager" and requested any additional case management/social services notes that may demonstrate adequate discharge planning. A rare few were able to send additional, useful documentation. For others, I urged them to document what they had just told me was done (using the "late entry" date) and fax it to me. Poor documentation certainly accounted for some-but not all-of the situations.


My "tour of duty" is not over, and I hope to bring you better news. At the least, please make sure that your documentation is complete, as more patients know of their appeal rights and Medicare is planning to advertise these rights more widely. More importantly, make sure that adequate discharge planning was actually done; unsafe discharges are being looked at more closely than ever.


Lest you feel downhearted with that report, I now have an "Important Message from Mom." Leah is an 84-year-old Medicare beneficiary who has experienced case management in two ways: during hospitalizations for herself and her 90-year-old spouse and has also attended a case management seminar. Here is her message for YOU. I have talked to the beneficiaries and heard that they need you; Leah's following comments confirm this.


To all case managers: it is time someone told you the truth about you!!


I believe that you have no idea how important and needed you really are, how much peace of mind, comfort, and well-being you bring to those lucky people under your wing, with your expertise-your caring expertise!! I know, because I, too, have needed you while I was afraid and completely lost in the hospital; leaving the hospital with a new and different illness is so scary.


I went to one of your seminars in Canada and heard you discussing some of your cases.1 I listened in amazement as you relayed to each other some of the things you did to make the patient more comfortable, found a procedure for better health care, improved their mental state, contacting doctors for the client-no detail was too small or too large. And you did it so matter-of-factly. This is what made me believe that you do not realize how special (and important) you are. I fell in love with you-and that is no small matter with such a big crowd!!


I may not be able to let everyone know about the wonderful job you do for them, but-by golly-I am going to put in a BIG REQUEST when I pop-off and tell God to put in a special wing for the Angels of Case Management: and believe me, you are in the "Angel" category. So, dear people, in another 120 years when you are ready to go, I'll be there to lead you to your rewards!!


1Discussions were generic and no names or identifying facts were used. [Context Link]


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Mission Statement:Professional Case Management is a peer-reviewed, progressive journal that crosses all case management settings. PCM uses evidenced-based articles to foster the exchange of ideas, elevate the standard of practice, and improve the quality of patient care.