COVID-19 Case Management and Utilization Management FAQ’s
On April 10, Xsolis hosted a second roundtable discussion on COVID-19. This session focused on how UR teams across hospitals are adapting as COVID-19 cases continue to climb, what we have learned about the disease in the past few weeks, and new updates on regulations and compliance. The expert panel included:
- Heather Bassett, MD Chief Medical Officer, XSOLIS
- Beth Shandor, DO, FACOI Physician Advisor, XSOLIS
- Steven Sandubrae, DO Senior Physician Advisor, XSOLIS
- Michelle Wyatt, DNP, MSN, RN, IQCI, CPHM Director of Clinical Best Practice, XSOLIS
- Crystal Nichols, MA, BSN, RN, ACM-RM, CLNC Senior Manager, Clinical Excellence, XSOLIS
- Patty Dietz, BSN, RN, CPHQ, ACM-RN, Clinical Sales Director, XSOLIS
Q: What are we hearing from our hospitals and partners about changes they are experiencing in the face of this crisis?
A: Some of our hospitals in the hard-hit New York area, for example, are seeing a census of more than 100 patients per day above normal volume. They’re short-staffed because many employees have tested positive for COVID-19. They have also experienced a significant surge in ICU beds. Teams are getting creative to adjust by turning ORs into ICUs, for example. Even more alarming is the increase in nurse to patient ratios which has risen in some cases to between 1:5 and 1:10. These experiences are limited to regions with high volumes of COVID-19 patients.
Less affected regions in the U.S. are seeing lower volumes and have been rotating staff off and on PTO as a result. Many are splitting teams, keeping some onsite and asking others to work remotely. Furloughs and layoffs are unfortunately occurring in some locations. With volumes down, focus is on the essential UR work such as regulatory requirements as staff are spending a lot of time now preparing for possible surges. There is a broad concern about the decreasing mental health of colleagues during these difficult and uncertain times. There is a strong need to advocate for our employee assistance programs available for staff for additional support. Hospital leaders need to ensure that the mental health of their staff is being addressed as a priority.
Q: What is the medical community saying about COVID-19?
A: In general, be mindful that not all patients are being hospitalized for COVID-19. Clinicians are narrowing in on patients that present with a dry cough, fever and chest pain. However, there is a lot of overlap between flu, other illnesses and COVID-19.
A: There is an increased risk of poor prognosis with COVID-19 if a patient has comorbidities or pre-existing conditions. A study in China shows that the fatality rate for COVID 19 in patients with chronic respiratory disease was 6.3% compared to the fatality rate of COVID-19 in those patients without a history of chronic respiratory disease (2.3%). Co-occurring conditions including COPD, CAD, and other respiratory diseases have been found to worsen the prognosis in patients with other coronaviruses that affect the respiratory system, such as those that cause SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome). This seems to be true for COVID-19. Additionally, vaping and cigarette smoking diminishes the ability to respond to infection and thus may have a significant impact on the morbidity and mortality of patients who get COVID-19.
Q: What surprising recovery trends and symptom presentations are being seen?
A: Among unusual trends are that some COVID-19 patients start to feel better then take a turn for the worse. They are experiencing a second wave after four or five days where they can really spiral down (due to the inflammatory process of our immune system). Also, it has been noted that a lot of people have been mis-diagnosed with presenting symptoms of chest pains who are sent straight to the Cath lab, only to learn they are not having a heart attack, but instead are positive for COVID-19. This leads to unnecessary hospital procedures.
Q: How effective is Convalescent Plasma (CP) Therapy on COVID-19 patients as seen in early studies?
A: Initial signs indicate that this therapy may be helpful in reversing symptoms of COVID-19. In a small research study, 10 people were given a dose of CP to see if they responded with an increase of antibodies to fight the disease. The effects of the plasma transfusion revealed decreased inflammatory markers such as CRPS, ALTs and ASTs. In three to five days, oxygen saturation increased. All symptoms in the 10 patients, especially fever, cough and chest pain disappeared or largely improved within 1-3 days of the CP transfusion. Even though this was a small study, it is encouraging to see such positive results and the conclusion shows CP may serve as a promising rescue option for severe COVID-19 patients.
Q: What regulatory changes have we seen? HIPAA compliance with telehealth?
A: CMS has issued many waivers within the last month, all of which are applicable to every provider in the country and none of which require the provider to “ask permission” from CMS to use it. For operational purposes, you still need to be HIPPA compliant, but these waivers were issued to help with COVID patient cases. (click here for more information)
Q: Are there insights on trends that we are seeing with AI and COVID-19?
A: A clear success story is Health Map, which picked up on new cases of pneumonia in Wuhan in late 2019 and was a source of early detection of COVID-19 through the assistance of artificial intelligence mapping and patterns. However, AI currently is somewhat limited in this pandemic overall due to lack of data. In addition, the data that we are seeing is not terribly straightforward with multiple outliers, etc. That said, there have been some benefits to using AI such as in making new drugs (or using existing drugs to mitigate COVID-19). These are great ways to see how we might treat this disease. (click here for further information)
Q: For hospitals that have not been hit yet, is there something they should be doing to get ready for COVID-19?
A: It is important to think about staff mitigation plans. This might include rotating staff or asking staff to take PTO to avoid being furloughed. Hospitals need to have a plan in place for if their staff members become ill. If there are staff that have recently left the clinical side and there is a need for a redeployment back into clinical areas, hospitals should determine if clinical training will be required to bring them back onboard. Hospitals should also be thinking about other technologies to help their team cope with this quickly evolving environment. Be transparent, be visible and communicate well.
Other ways to prepare:
- Operationalize how to increase their bed capacity rapidly if needed.
- Create a coverage plan for your teams to be able to centralize; some staff could be repurposed to bedside.
- Create a plan to avoid cross-contamination. For example, ask questions such as, “can units be converted to negative pressure units?”
- Stay abreast of legislative rules that impact your facility and patients.
- Convene a team with PAs, case managers and the hospitalists to address care coordination issues so beds can be opened up when surge happens.
- Draft backup plans outlining where to put patients while still maintaining guidelines and adequate supplies of PPE.
- Have an IT strategy if you need to send your staff home to work (UR staff is considered non-essential in many cases).
Q: What effect is COVID-19 having on discharge planning?
A: There are other patients in the hospital besides COVID-19 patients. Those patients are also critical for flow. Stay in contact with vendors, payers and providers. If patients are sent home, ask if they have transportation, medication and groceries. Determine how hospitals will follow up with them so they can keep them at home if they do have to be discharged. Provide clear direction and clear expectations with families regarding visitation policies and procedures, etc. Keep the patient at center of focus.
Q: How do I deal with discharge to a SNF for COVID-19 patients?
A: Some are requiring negative COVID-19 tests on all patients. Sometimes even multiple negative results are now required. There are many inconsistent protocols at SNFs within any one region. This is a concern as it affects LOS. If the patient is medically ready to be discharged, hospitals do not want or need to keep them there as they may be exposed to hospital-acquired illnesses. (click here for further information)
Q: It is my understanding that UR is still required. Are most hospitals just modifying how frequently they are reviewing patients?
A: Right now, COPs are waived and a lot of policies are individual hospital established policies. The Conditions of Participation state that you just need to review a patient case sometime before, during or after admission, but it doesn’t specify the exact time. Since those requirements are waived, hospitals can decide how often they are reviewing patients. The hospital contracting department should reach out to payers to understand their expectations.
Q: How fast is XSOLIS able to adapt the bed locations in the software to support surges at hospitals as they find ways to get creative with bed space in their facility?
A: Different hospitals have had to adapt in different ways. Some have transitioned rooms from private to semi-private. Some either added a new floor or wing. Still others added tents in new dedicated spaces. XSOLIS is quickly able to get those new configurations and beds into the platform. We have our IT team working with clients to understand if they have new beds or floors added so they can still be managed effectively.
Q: How are hospitals managing the liberalization directives that are coming from payers? Is it prudent to secure revenue and continue to review cases if hospitals are able?
A: Yes, if you can provide the same UR that you used to, you should continue in that manner. But if you don’t have the capacity to perform UR the way you used to, be sure to get the payer involved early. Some payers have loosened requirements right now for portals, authorizations, etc. Find out if they have changed any of their practices due to COVID-19. Payers are not requiring typical UR up front in many cases. This does not necessarily mean you will be getting denials in the months to come. But be sure you are on the same page with payers and put a good faith effort in up front to help stabilize scenarios on the back end.
Q: My hospital is concerned that the waiver of authorizations from payers that exist now will mean take backs and retro audits on the back end.
A: It is true that payers aren’t defining that process currently. Be sure to involve your provider reps in those communications with your payer if you see a lot of retro audits and denials on the back end.
Q: What are you seeing regarding isolation precautions in the home for patients transitioned to home care?
A: Providers should follow the CDC guidelines which state that a patient should self-quarantine for 14 days from time of diagnosis or possible exposure. Wash hands frequently and do not touch your eyes, nose or mouth. Others exposed should also be quarantined. Additionally, a mask should be worn to prevent transmission within the house. Wipe down surfaces frequently with a disinfectant.
Q: What’s the financial impact on hospitals regarding the elimination in many cases of elective or outpatient services?
A: It is a fact that with the removal of those services, revenue is declining resulting in furloughs in many parts of the country. Leadership teams are doing their best to make that loss up somehow and looking to the CARES ACT for help. CMS is also looking at the re-distribution of those funds.