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Why Pre-admission Screening Matters to Post-Acute Care Institutions

The federal government pays more than 40% of all money spent on healthcare in the U.S. and it is focused like never before on managing those costs. Along with reducing already low reimbursement levels, CMS will look to two primary means for cost reduction–utilization and admissions review and reimbursements tied to outcomes. For post-acute care facilities this translates into a single imperative – “admitting the appropriate patient”.

For years, “appropriateness” reviews have been driven by the requirements of private payers. Short term acute care hospitals routinely use payer criteria to determine appropriateness for admission. Commercial payers have used preadmission screening in order to reduce over-utilization from their side of the business. Post-acute care facilities can likewise benefit from preadmission appropriateness reviews, but in addition to payer requirements their criteria should identify patients that best match their individual care programs.

Matching patients to care programs means a more complete picture of a patient’s overall health – for example unrecognized co-morbidities – before they enter your facility. And this means a better alignment between your patient’s needs and your facility’s resources. What benefits can such alignment provide? In addition to better compliance, comprehensive preadmission reviews can help lower operating costs associated with caring for patients. And patients that align with a facility’s strengths will necessarily see better clinical outcomes. The question is how to implement preadmission review without slowing down the admissions process and unduly increasing the cost of admitting patients?

The key to implementing a cost-effective review process is to combine currently available web-based technologies with a workflow that promotes “just in time” collaborative review and decision support. New approaches in content management allow non-technical end users to create and edit online assessments without costly programming resources. Roles-based views of patient data give admission nurses and preadmission medical review team the ability to hone in on just the information they need to quickly assess a patient, with more expensive resources like clinicians involved on an as-needed basis. And such a system becomes self-documenting as well, with referral metrics and employee performance data collected as a matter of course.

New online technologies can manage the preadmission assessment process, but it is still up to each facility to determine what an appropriate patient looks like to them. Many facilities will consider both economic realities of care and quality of care considerations when balancing the measurement of appropriateness for a particular post-acute care setting. As already mentioned, payer requirements will still be important, as well as requirements for accreditation programs like the Joint Commission. Institutions will also want to assess operational measures such as over/under utilization for specific programs or loss of patient referrals due to lack of resources. As a starting point, we offer the following for consideration:

  • The preadmission screening system should collect information necessary to identify reimbursement requirements and demographic information for planned and actual admissions.
  • Clinical indicators that will assist preadmission reviewers evaluate patients against established criteria of medical appropriateness, with appropriateness information available to physicians on a “just in time” basis.
  • The preadmission system should have the ability to follow patients through the preadmission process and report on any unmet requirements, particularly tied to compliance.
  • The preadmission system should provide volume and dollar values of denials by insurers to report on the effectiveness of preadmission screening.

In conclusion, a systematic approach to preadmission appropriateness reviews can provide post-acute care facilities the benefit of selecting the appropriate patient and demonstrating better outcomes. A successful system/process will reduce the risk of improperly classified patients leading to retrospective reclassification or payment denials. In today’s environment where institutions are working with razor-thin margins, every healthcare executive should pay more attention to their preadmission process.