Sources of Admission
Admission to the hospital can be from many sources. An individual can be admitted to the hospital from an existing hospital by way of (in network transfer). An in-network transfer can happen by the request of the health plan, medical group, the patient or family. Patients can be transferred to a network hospital if they are deemed stable for transfer by both the transferring physician and the accepting physician. Transfer to another hospital can be for a higher level of care. In the case of a member who has an HMO plan, an in-network transfer would be necessary due to better contracted rates and the ability to continually manage the care after discharge from the hospital.
Another source for admission to the hospital can be from clinics or physician offices. If the provider feels that the patient needs to be admitted to the hospital, arrangements can be made for a transfer. The transfer to the hospital whether it is by privately owned vehicle, medical-van, or ambulance will be determined by the sending provider based on medical necessity. The patient can be transferred to the emergency room or as a direct admission to a specified unit of the hospital. This again depends on medical necessity.
In some cases, patients can be placed in the hospital under what is normally referred to as, observation status. During observation, a patient is placed into a standard room and is provided meals and basic nursing services. This is a time for observation and testing. The attending provider has up to 72 hours to decide whether the patient can go home or be fully admitted to the hospital. Medicare part (B) pays for the services on observation. However, the patient might be responsible for any co-pays and additional out of pocket expense such as medication. Most HMO plans typically have no co payments under observation status and not all insurance plans recognize observation status. It is wise to understand what your health plan pays for prior to being admitted. The observation status is used as a cost-saving alternative to full admission to the hospital. This in no way places the patient at risk medically. Under Medicare rules, a patient can challenge the observation status by appeal. If you feel that you should be placed as an inpatient, ask the physician to fully explain why you should be on Observation status. To help save on cost, ask the physician if you can use you own medication while in the hospital. Normally they would agree to this.
If the patient meets the criteria, they can be fully admitted to the hospital as an inpatient. For Medicare, this is paid for by part (A) of the entitlement. You, as the patient, have the right to know up front whether you are going to be admitted as an observation patient or an inpatient. For Medicare patients, it is standard protocol for the case management staff of the hospital to verify criteria of admission utilizing guidelines set forth by Medicare. In some cases, an observation patient can be changed to an inpatient depending on meeting the criteria.
Levels of Care
Level of care in the hospital is determined by medical criteria and need. Typically, there are four levels of care in any given hospital which are the medical surgical unit, telemetry unit, progressive care unit, and intensive care unit. Other levels include maternity, neonatal intensive care unit, post anesthesia care unit, and behavioral health.
The medical surgical unit is for patients who do not require intensive vital signs monitoring or cardiac monitoring. The nurse to patient ratio is higher in this unit compared to the other units. In California, the nurse to patient ratio is 5 to 1. The medical surgical unit is for patients who do not have a life-threatening diagnosis and have a general medical or surgical need. Medications that are given on this unit do not need extensive monitoring.
The telemetry unit is reserved for patients who require more intensive vital signs observation and cardiac monitoring. The patients who are admitted to this unit are more prone to cardiac problems. Certain medications that require cardiac monitoring can be given on this unit. Typical diagnosis can be chest pain, syncope, strokes and myocardial infarctions. The standard ratio for this type of unit in California is four to one.
Progressive Care Unit
The progressive care unit is also known as the definitive observation unit. This unit is typically reserved for more unstable patients that require a higher level of vital signs and cardiac monitoring. This standard ratio in California for this unit is 3 to 1. This tends to be unit where downgraded ICU patients can go depending on medical criteria. In this unit medications that need even more intensive monitoring can be administered.
Intensive Care Unit
The intensive care unit is reserved for patients who need the highest level of medical monitoring. All types of medications and services can be rendered in the intensive care unit. Typical conditions that warrant an intensive care unit admission can are, cardiac arrest, extensive trauma, traumatic brain injury, intracranial bleeds, diabetic coma, myocardial infarction, respiratory failure with artificial ventilation and extremely high-risk patients. The standard ratio for this unit tends to be 2 to 1. In some cases, the ratio can change to 1 to 1.
Discharge planning is a key factor in the success of recovering from a stay in the hospital. Without a good discharge plan, the care that was rendered in the hospital loses its value and effectiveness and can hinder any effort to a meaningful recovery. Discharge planning can involve activity that can help facilitate a patient's movement from the hospital to another facility or to their home. It is a multidisciplinary approach which involves key members of a health care team: nurses, social workers, physicians and other health professionals.
The goal of discharge planning is to enhance and support the continuity of care out of the hospital setting this process begins early in the admission. In some cases, discharge planning can take place prior to admission. An example would be for a scheduled knee or hip surgery. Discharge planning would be crucial to ensure a good outcome. Will you need physical therapy after surgery? How long will you need it? Where would it take place? Does your insurance cover (at home) physical therapy? Do you live in a two-story house? Do you spend you sleeping time upstairs? Would you be able to negotiate the stairs after surgery? Will you need any equipment? Does your insurance cover the cost? Any co pays?
These are many things to consider with discharge planning. While in the hospital, the discharge planner is there to help with all of this. However, it is still a good idea to plan ahead if possible. In fact, even if you do not plan on having elective surgery any time soon, it would be a good idea to find out what your insurance covers.
The role of the hospital has evolved over time. Today the hospital’s main goal is to get a patient stable and started on the path to recovery. The patient is admitted stabilizing an acute or exacerbated chronic condition, which is also referred to as acute on-chronic condition. Recovery and convalescence can take place, if safe to do so, at home or at a skilled nursing facility. Physicians determine if a patient is stable by looking at many factors such as: stable vital signs, stable or stabilizing blood values, pain control, function and safe discharge plan. So, the days of patients staying in the hospital until almost full recovery are over. Back in the 1970’s it was common practice to keep children in the hospital for 5 to 7 days following tonsillectomy (removing the tonsils). Today it is done as an outpatient surgical procedure.
Prior to your discharge from the hospital a variety of things will happen. These will include:
1. After-care instructions. The provider will provide a written discharge plan which will include instructions such as; watching for an increase in temperature, increasing pain, or any change in condition and the steps to take. If you will be going home with a drain such as a Foley catheter (Urine) and bag, it would be prudent for you to undergo basic maintenance training before discharge from the hospital. This can be provided by your bedside nurse. In some cases, home health can be arranged to help further educate you, a family member or designated care giver. This can also be applied toward wound care and self-injections.
2. Medication reconciliation. This is where the provider will provide a list of medications that you should continue or discontinue taking after discharge from the hospital. Some hospitals provide the medication reconciliation that doubles as a prescription that you can take to your pharmacy. It is highly advisable that you take this medication reconciliation sheet to your pharmacy so they can be thoroughly updated on your medication regimen. Do not leave the hospital unless you have a full understanding of what medications you are to take and not to take.
3. Follow-up appointments. It is very important for you to follow-up with your primary care provider (PCP) and or specialists after discharge from hospital. Your PCP should have a good understanding why you were admitted. Together with your PCP, you can discuss and formulate a better care plan suited to your ailment which led to your hospitalization. Re admissions to the hospital can be reduced with good quality follow-ups. In most cases the hospital staff or case manager can help arrange any follow appointments that might be necessary.
Appealing a Discharge
Medicare beneficiaries have the right to initiate an appeal if you feel that you are being discharged too soon from the hospital. It is common practice for the hospital to furnish you with an Important Message (IM) notice from Medicare notice two days prior to your discharge date. This IM notice is to inform you if your rights under Medicare to appeal a discharge. If you do not receive this notice, ask for one. There is a toll-free number for you or your designated representative to call and initiate the appeal process. After the phone call the hospital will be notified of the request. The hospital will then send your medical record of your stay to an impartial third party to review your case and render a verdict. They will either side with you or the hospital. During the appeal process you will not be discharged and you will not be charged for (except for applicable co-pays or deductibles) the days during the appeals process. Once the decision has been made the hospital will let you know. If the third-party sides with the hospital then it is expected for you to be discharged the following day before noon. If you stay past that point you could be liable for the cost going forward.
If you are to be discharged to a Long Term Acute Care Facility (LTAC) then the appeals process would not apply. You would be transferring to the same level of care. The appeals only apply to being discharged to a lower level of care.
Patient Rights under Medicare
The important message from Medicare explains that:
• You have the right to get all medically necessary hospital services
• Your right to be involved in any decisions that the hospital, your doctor, or anyone else makes about your hospitals services and to know who will pay for them
• Your right to get the services you need after you leave the hospital
• Your right to appeal a discharge decision and the steps for appealing the decision
• The circumstances under which you will or won’t have to pay for charges for continuing to stay in the hospital
• Information on your right to receive a detailed notice about why your covered services are ending
Skilled Nursing Facility
The skilled nursing facility (SNF) is a transitional care facility capable of providing skilled nursing care to individuals that are not at the level of acute care but are not functional enough for home. Here an individual can receive physical therapy, occupational therapy, IV therapy, and pain control management. Most SNF’s have the same compliment of staff as do hospitals such as: Physical Therapist, Occupational Therapists, Respiratory Therapists, Nurses, Nurse assistants, food service workers, Case managers and so on.
Your treatment is still physician guided and therapy driven, meaning that your doctor will oversee you care, but it is the therapy that sets the tone. Therapy can include; physical, occupational, respiratory, speech. Other therapy can include wound care and IV antibiotics.
Not all insurance plans cover a stay at the SNF, especially if your insurance comes from your employer. It is a good idea to check and see if you have the benefit. Not all SNF’s are created equal. They vary in size, look and location. The SNF can be much different than the hospital. Most hospitals have private rooms. Insurance pays for a semi-private room unless there is a medical reason for you to have a private room at a SNF.
Over the years, physicians have been opting for patients to have more of their care completed in the home. This has been proven to be a safe and practical alternative to a full admission to the hospital. In fact, some hospitals and medical groups have started programs such as “hospital at home”. This is where a patient can receive many services at home much like they would if they were in the hospital. This can include physical and occupational therapy, IV therapy (including antibiotics), wound care, X-rays, Tube feedings, lab draws and physician visits.
To receive Home Health services a patient must meet certain criteria set forth by the health plan and/ or Medicare. For some services, Medicare requires that a patient to be “home bound” which means that the physician believes that it would be too burdensome for the patient to leave the home without the assistance of another human or if leaving the house is medically contraindicated. The services must also fall under the skill level of service which means care provided by licensed medical professionals such as Physical and Occupational therapist, Registered and Licensed Vocational Nurses, Speech Therapists, Social Workers and others. Home care that utilizes caretakers, home health aides or patient companions is not normally covered. There are some instances where home health cannot be an option. If you live in a remote area away from any substantially sized city, home health services can be scarce to none. This is a possibility which needs to be considered before considering home health. It would be wise to discuss this with your medical team and case manager at the earliest possible time so that options can be explored.
Long Term Acute Care facility (LTAC)
LTAC’s are facilities which cater to patients who require a longer acute care stay. These facilities specialize in long term care at a level comparable to acute hospitals. LTAC’s tend to be a more affordable way to deliver long term care without compromising quality. LTAC’s can accommodate ventilator supported patients, patients who require very complex wound care, complex IV medication and patients who require care which would last more than 25 days.
Transportation via ambulance to the emergency room is normally a covered benefit, depending on the plan. Ambulance transportation back to home is not normally covered unless the member is bed bound or has an orthopedic device which is too cumbersome to use in a car or medi-van. Ambulances are also approved for transportation if the patient must be medically monitored by a qualified EMT, Paramedic or Critical Care Nurse. Hospitals to LTAC, hospital to hospital, SNF to hospital (if an acute or emergent condition) are covered. Remember the above criteria is set for Medicare, these criteria might not necessarily be used by private health plans. Check with your health plan for transportation benefits.
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