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Leveraging Care Navigators to Deliver Impact Medicare Compliance

  • Stephania Olmendi
  • D. Johnson Small Image

By Stephania Olamendi and Dawn Hawkins Johnson

Background

Starting in 2011, the Center of Medicare and Medicaid Services (CMS) has required health care systems to deliver the Important Message from Medicare (IM) to all Medicare beneficiaries who are hospital inpatients. This admission notice provides beneficiaries and representatives a written notice about their hospital discharge appeal rights.

CMS regulation dictates that IM delivery follow guidelines that include specific delivery methods at different times during an inpatient hospital stay. These strict guidelines can make meeting the 100% CMS requirement of compliance difficult to attain in facilities that are already striving to improve quality scores, patient outcomes and satisfaction metrics. Prioritizing and acknowledging the need to commit resources to this non-incentive affiliated requirement is difficult, as patient-related improved outcomes, decreased costs and other indicators of quality are not directly tied to this letter’s delivery. In 2017, the American Hospital Association (AHA) assembled a report1 directed to CMS on behalf of nearly 5,000 member health care organizations, including 270,000 affiliated physicians, 2 million nurses and caregivers. This report outlined the burden faced by health care systems to comply with the specific guidelines on regulatory processes, highlighting the IM delivery process.

 

The Solution

One innovative solution to address these challenges is the utilization of trained non-licensed pre-health students to assist with IM delivery. Magnet recognized St. Joseph Hospital of Orange (SJO), one of the 51 hospitals in Providence/St. Joseph network, partnered with COPE Health Solutions in 2017 to train and deploy Care Navigators to support the case management team with increasing their IM letter compliance hospital wide. This process-oriented requirement exposes non-licensed, health career seeking students to federal requirements, allowing them to hone their interpersonal and communication skills and providing them with a unique opportunity to see the immediate impact of their contributions within a health care delivery system.

Training is a crucial factor for the successful integration of these students to SJO patient care team and workflows. Part of the general Care Navigator onboarding includes a 20-hour in-person training that utilizes multiple modalities to introduce topics (such as the changing health care landscape, integrated health care delivery models, evidence-based patient centered care strategies, social determinants of health, behavioral health, etc.) that prepare them to work alongside the case management team. This training is designed to build a workforce with relevant competencies to the current health care climate and refined through a curriculum reinforced in site-specific learning.

New Care Navigator Scholars complete an additional four hours of site specific training to review customized workflows, scripts and escalation protocols to be used during their shifts to orient. Two key elements of their site-specific training include a comprehensive hands-on EMR training facilitated by a SJO nurse educator and peer-to-peer shadowing opportunities to ensure a warm handoff between incoming and outgoing Care Navigator cohorts.

Once fully trained, Care Navigator are equipped to support the team with various tasks including IM delivery. Under the supervision of a case manager, Care Navigators follow CMS IM delivery guidelines to screen for member eligibility, inform recipients of discharge rights upon timely IM delivery and complete follow up documentation required. On any given month, Care Navigator can hand deliver up to 90 IM letters. Taking on these activities allows case managers to focus their time operating at the top of their license and focusing on the patients discharge planning.

 

Results

Five months after program implementation, there was a 15% increase in overall hospital IM delivery compliance. The first year of program implementation, Care Navigators assisted SJO case management team to deliver over 500 IM letters, reaching a hospital wide compliance of 89%, ten percent higher than that of the year prior to program implementation.

For more than two years, Care Navigators have been integrated with SJO case management team, supporting case managers and patient care coordinators to meet organization milestones while helping to maintain SJO’s standard o compassionate, reliable and safe care for all patients. As SJO continues to develop this pipeline of Care Navigators, SJO is cultivating their future health care workforce with ties to the community and loyalties to the organization. Care Navigators eagerness and excitement for exploring the health care industry and their renewed energy for the tasks they complete, influences positive team dynamics and encourages SJO staff to act as role models and operate at the top of their license.

As an exchange, Care Navigator Scholars gain the opportunity to learn health care concepts firsthand they would otherwise not be exposed to until years into their professional career. These are experiences that pave the foundation and guide young professionals further throughout their journey to become well-rounded, compassionate health care professionals.

 

Endnotes

1 https://www.aha.org/system/files/advocacy-issues/letter/2017/170911-let-nickels-cms-opps-regulatory-relief.pdf

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