1. Facilitates patient’s transfer to capped hospital when admitted to an out of network or out of capped facility and needs continued hospitalization. The nurse follows the Out of Network Transfer Protocol below:
a. The nurse calls the assigned hospitalist where the patient is to be transferred to and lets him/her know that the current attending physician will be calling to discuss continuation of care or vice-versa.
b. The nurse calls the capitated hospital to check if bed is available, provides patient’s demographic information and faxes a face-sheet or pertinent records to the hospital if requested.
c. The nurse checks if MD-to-MD has occurred and once confirmed that the hospitalist has accepted the patient’s transfer and if bed is available, the nurse generates a tracking number for the ambulance.
d. The nurse calls the facility where the patient is being transferred from in order to give the room number assigned for the patient, the phone number for the nurse’s station where the releasing hospital has to call for report and gives the authorization generated for the ambulance.
2. Facilitates Emergency Room (ER) transfers when patients require admission. The nurse assesses and verifies if the patient is stable for transfer to capped hospital, if stable will proceed to Step 1a. If unstable or no bed is available, the nurse gives authorization to admit the patient
3. Documents the specific reason/s why patient is not repatriated back into network or capped facility.
4. Verifies if the attending physician assigned on the case is the correct hospitalist. If assigned attending is not the correct hospitalist, the nurse switches the providers by calling the contracted hospitalist on the case, once accepted, the nurse informs the attending provider that IPA contracted hospitalist will be taking over the case. The nurse e-mails Provider Relations Department of the incorrect attending physician assignment for hospital ER and admitting staff education to ensure correct Hospitalist assignment on future admissions.
5. Coordinates transfers of patients to tertiary facilities for higher level of care.
6. Calls the hospital UR Department to request initial reviews, concurrent reviews and discharge planning for IPA members.
7. Documents clinical reviews in the EZ-cap system.
8. Assigns the appropriate Level of Care (LOC) and approves the authorization if deemed medically necessary using MCG or Inter-Qual (CareEnhance Review Manager Enterprise) guidelines.
9. Identifies unnecessary or aberrant days and forwards the information to the Medical Director and Inpatient UM Manager for final review and determination of potential denial of days.
10. Forwards the case to the Notice of Action (NOA) Coordinator for denial or modification letter generation if final determination is to DENY or modify continued stay. The nurse ensures that the case is closed accurately and documents on Memo Line #2 of EZ cap the number of approved and denied days i.e. Approved 2 days, denied 2 days.
11. Facilitates discharge planning to home, skilled nursing facility, hospice care, etc. Documents discharge disposition on the date of patient’s discharge.
12. Provides authorization for discharge needs i.e. home health care PT, OT, skilled nursing visits, Home infusion, Self-injectable drugs, DME, medical supplies, etc.
13. Reviews and documents clinical reviews of SNF patients at least weekly.
14. Forwards to Disenrollment Coordinator information of SNF patient who is admitted to long-term care and has resided in a nursing facility beyond 30 days. After the month of admission to facilitate disenrollment of member from Managed Care Medi-Cal back to Fee for Service Medi-Cal.
15. Provides authorization for inter-facility ambulance transfers.
16. Attends the daily inpatient meeting to go over daily bed day reports.
17. Reviews and maintains bed day logs weekly and monthly to ensure that Status 7 or pending/open cases are closed timely.
18. Refers potential re-admissions to Outpatient High Risk Case Management for follow-up post discharge.
19. Refers any potential quality of care issues (PQI) identified to the QI Department for review of QI cases.