BY, RN, CCM, MHA
HOW THE COVID-19 PANDEMIC STARTED
Near the start of the year 2020, public health officials reported the first COVID-19-positive cases in the U.S. and the onset of the pandemic. The first major problem the hospitals faced was expanding ICU bed capacity for COVID-19-positive patients. In the northeastern U.S., hospital predictions of an impending COVID-19 surge became a reality, and disaster plan efforts were initiated. Hospitals announced cancellations of elective procedures, and hospital command posts took over daily operations to execute COVID-19 detailed surge plans to conserve resources and expand to full capacity and beyond. COVID-19 surge planning was initiated should hospital bed capacity need to double or triple.
As an interim director of case management at a community hospital, I was challenged to think outside the box and develop a surge plan for my department. The master plan outlined how each department would adapt to an increase in patient volume and identified areas on and off the hospital campus that could be utilized if needed. I maintained contact with other hospital directors of case management who were also challenged by this crisis.
The pandemic was extremely challenging for leaders and staff to live through as new information about the virus was reported. The following is a list of important lessons learned and issues that others could face should the surge recur:
Hospital Staff Safety and Well-being Are Critical. In these uncertain times, regular department communication by e-mail and phone conference calls is essential. Many hospitals offer no-cost employee assistance services to help employees who request the services of a professional counselor. Special COVID-19 cross-functional teams should be organized to do rounds on units to answer questions about the changes. Infection control is instrumental in reviewing procedures and working with each team. Employee health management, screening of staff who may have become ill, and strict protocols for quarantine are critical. Staff members should be required to report for temperature checks upon shift start. Leaders can hold periodic hospital-wide town hall meetings to provide updates and reduce anxiety about the pandemic.
New COVID-19 Case Management Surge Planning – Surge planning is a disaster plan that provides an overview of each stage of the ramp-up and identifies current state, outcomes, concerns, and back-up plans. Most hospitals are familiar with disaster department planning for hurricanes, blizzards, flooding, and other natural catastrophes. The COVID-19 surge planning that many hospital systems primarily invoked at the initial onset was different and lasted for months. Preparing a COVID-19 surge plan requires all departments to evaluate their resources for supporting an increased bed census of COVID-19 patients. Changes in procedures are adopted. The Centers for Medicare & Medicaid Services (CMS) has waived patient choice of facility transfer and quality of care metrics as skilled nursing facilities and post-acute care settings refused to receive patients and are closed to admissions. Explanation to patients and families about finding post-recovery care in the least restrictive setting is crucial. Working with home health agencies to revise discharge planning checklists to address patient quarantine isolation levels and personal protective equipment (PPE) needs is vital. Home evaluations are a necessary part of the assessment process to accommodate patient functional limitations and ensure equipment safety. Discharge planners must think outside the box in working with varying patient populations and prepare for the unexpected.
Implementing Early Ambulation Programs on COVID-19 Units – Early ambulation programs are essential for patients to recover. They require PT, OT, and nursing to coordinate patient ambulation several times a day with an exercise program. A progressive ambulation program is necessary for patients to regain endurance and recover from deconditioning.
IT Decision Support and Electronic Medical Record Updates – Many hospital IT departments should strive to adapt the electronic medical record to include COVID-19-related diagnoses, symptoms, and test results. Post-discharge COVID-19-related information packets should be made available to send to post-discharge providers.
Determining the Least Restrictive Setting for Discharge – Hospitals navigators and clinical specialists should be involved in planning by patient population and offered recommendations to expedite a smooth transition to the least restrictive setting. Respiratory navigators with pulmonary specialists must assist in weaning patients off vents and high oxygen levels to safely go home with oxygen. Through close collaboration, respiratory navigators, pharmacists, hospitalists, home health liaisons and case managers can resolve the most challenging patient cases.
Long-Term Placement Barriers – Many hospital discharge leaders are faced with unexpected barriers and delays. In a pandemic, long-term and senior living facilities are often not able to accept returning patients, and alternative plans must be explored. It is recommended that hospitals evaluate applying for CMS swing bed waivers, and determine a designated area for state-licensed swing beds. Many hospitals have worked to determine alternative settings for patients needing custodial care only.
Re-evaluate Initial Utilization Review Efforts – The primary point of access for COVID-19 patients is the emergency department. As such, many hospitals can re-assign case managers to the ED to perform utilization review in real time before admission orders are written. Ideally, UR coverage in the ED extends seven days a week during peak hours. Meetings with the ED director enables ED CM nurses via text messages to advise and consult ED providers and make recommendations for OBS vs. inpatient admit status. This yields fewer denials from payers, improved documentation, and reduces the number of Medicare Code 44 certifications.
Reducing Long Lengths of Stay – In COVID-19 it is difficult to reduce the lengths of stay unless new approaches to rounding are implemented. One approach is to assign a virtual team to review COVID-19-positive and long-stay patients every day. The ideal team should include a physician advisor, hospitalist leader, case manager, utilization reviewer, therapist, and nurse. It is also helpful to ask a coding expert to weigh in on documentation needed to support DRG working diagnoses. Daily rounding should focus on current status, nursing/ PT/OT updates, progressing the plan of care, eliminating barriers, and escalating issues to ensure timely discharges.
Cost/Benefit Analysis – Underinsured, undocumented, and homeless patients are the most challenging for any case management department. Effective planning is directly proportional to available charity care and agencies available in the community. Hospitals should carefully evaluate their charity care programs and set up guidelines for case management departments to use scholarship funds as available to expedite discharges. In many cases, it is far more cost-effective to offer a supply of medications or durable medical equipment than to extend patient stays.
Utilize Decision Support Tools to Determine the Level of Care – Commercial medical necessity guidelines used by insurers and hospitals are care pathways that often do not fit the COVID-19-positive patient presentation. The severity of symptoms and intensity of services is a much better benchmark to evaluate the medical necessity of care level for inpatient or observation. Some hospitals have been able to use artificial intelligence to risk-adjust patients and help determine inpatient care levels.
Home Health and Skilled Nursing Home Coalitions – Hospitals who have invested in home and skilled nursing coalitions have opportunities to plan for COVID-19 surges. Plans can be explored with skilled nursing partners to accept COVID-19 patients for rehabilitation. Case management departments tracking the nursing homes where patients are transferred can utilize this information to review readmission rates and work with partners willing to accept patients directly from the ED.
Ramping Up Telemedicine and COVID-19 Clinic Capabilities – It takes work to ramp up telemedicine and COVID-19 clinic capabilities. Many patients may find primary care practices closed or limited during a COVID-19 surge and have no way of gaining prescription refills or getting problems resolved. Hospitals can prevent readmissions by leveraging a user-friendly telemedicine service and COVID-19 clinic available for discharged patients.
COVID-19 Advocacy Groups, Family Support, and Crisis Intervention – Hospital financial and social work departments should assist as they are able. Should a next wave come, it will require coalitions to address the community network of advocacy and support services necessary to help individuals and families in crisis.
Temporary Housing Solutions – Hospital system task forces should explore alternative settings to house post-acute care patients. As patients move out of hospitals and fewer are admitted, transient community housing settings will be needed if another COVID-19 wave occurs. Communities should prepare to address the problems of temporary housing for COVID-19 recovering discharged patients with limited social support systems to prevent a public health disaster.
Many of the U.S. northeastern hospitals are now in recovery planning, and things are improving with elective surgeries being rescheduled and services back to a new normal. Case management colleagues concur that the most important lessons learned through the first months of the COVID-19 pandemic were to keep staff safe and informed, execute a comprehensive plan, collaborate with stakeholders, make revisions as necessary, and track successes. The hospitals and health systems that experienced the first COVID-19 surge deserve recognition for persevering through incredible challenges. Planning for a second wave may take additional experts and outside consultants to map out and improve surge planning.