Direct Supervision of Hospital Outpatient Therapeutic Services CAH Perspective and Concerns

1. Direct Supervision of Hospital Outpatient Therapeutic ServicesCAH Perspective and Concerns Todd Schaffer, MD Carrington Health Center Carrington, North Dakota Catholic Health Initiatives

2. Issues • CMS has directed that certain hospital outpatient therapeutic procedures require direct supervision until “medically stable” and then general supervision can occur with explicit documentation of when that stability occurs. • Carrington Health Center is requesting a change from Direct Supervision to General Supervision for specific items listed below with details on the following slides: • Observation stays • IV therapies including hydration • Subcutaneous therapies

3. Observation Stays HCPCS code G0378: Hospital observation service per hour HCPCS Code G0379: Direct admission of patient for hospital observation care • Complexity:always lower than acute stays. • Acuity:the higher acuity patients would already be screened out and admitted or transferred to an acute care setting. Protocols for patient treatment are identical in both an Observation Stay and an Acute Care setting.

4. Observation Stays • Probability of unexpected or adverse patient events:much less than an acute care patient that has higher acuity. The sickest patients that are considered high acuity will have been placed into an acute care setting. • Expectation of rapid clinical change:very low as typically an observation patient does not have multiple complex issues or the patient would be in an acute care setting. • Recent changes affecting patient safety:virtual healthcare availability, smart pumps, electronic diagnostic interpretations, scanners for EKGs/labs, etc. that allow for rapid diagnosis. • Clinical context care delivered: exactly the same as a much sicker and more unstable acute care patients.

5. Intravenous Infusions, Hydration HCPCS Code 96360: Intravenous infusion, hydration; initial, 31 minutes to 1 hour HCPCS Code 96361: Intravenous infusion, hydration; each additional hour • Complexity: very low. • Acuity: the higher acuity patients would already be screened out and admitted or transferred to an acute care setting. Protocols for patient treatment are identical in both an Observation Stay and an Acute Care setting for patients using the same fluids.

6. Intravenous Infusions, Hydration • Probability of adverse event: very low as hydration therapy does not include any medication. • Expectations of rapid clinical change: minimal to see decline in a patient. Most common rapid clinical change would be seen in the pediatric and elderly population where IV hydration can lead to dramatic improvement in a short period of time in this population that is dehydrated.

7. Intravenous Infusion for Therapy, Prophylaxis, or Diagnosis HCPCS code 96365: specific substances or drug, initial, up to 1 hour HCPCS Code 96366: Each additional hour in addition to 96365 HCPCS Code 96367: Additional sequential infusion, up to 1 hour in addition to 96365 initial HCPCS Code 96368: Concurrent infusion in addition to primary procedure

8. Intravenous Infusion of Medications • Complexity: very low. Smart pump technology has largely taken human error out of rate calculations in particular for complex medications. Single dose vials of medications are used that eliminates the need to draw specific doses of medication out of a multi dose vial where errors are more prone to occur. • Acuity: higher acuity patients would already be screened out and admitted or transferred to an acute care setting. Protocols for patient treatment are identical in both an Observation Stay and an Acute Care setting for patients who are administered the same medications. • Probability of adverse event: very low, depending on the medication. There is also a triple check system in place as the physician, NPP, Pharmacist, and Nurse all check for allergies. • Expectations of rapid clinical change: if a patient receives treatment in an outpatient setting it would be very low otherwise the patient would be admitted to the acute care setting.

9. Intravenous Infusions of Medications • Recent changes in technology: smart pump technology; telepharmacy allowing 24/7 pharmacy coverage provides high quality patient care. • Clinical context in which the service is delivered: treatment is designed for the patient that does not require the same treatment as a higher acuity or sicker and more unstable acute care patient, but still requires a higher level treatment than oral medications can provide.

10. Therapeutic, Prophylactic, or Diagnostic Injections HCPCS Code 96372: Specify substance or drug; subcutaneous or intramuscular HCPCS Code 96374: Specify substance or drug for intravenous push, single or initial substance/drug HCPCS Code 96375: Specify substance or drug; each additional sequential intravenous push of a new substance/drug in addition to the primary procedure HCPCS Code 96376: Specify substance or drug; each additional sequential intravenous push of the same substance/drug provided in a facility

11. Therapeutic, Prophylactic, or Diagnostic Injections • Complexity: subcutaneous and intramuscular injections are a basic nursing service taught early on in nursing school. • Acuity: The higher acuity patients would already be screened out and admitted or transferred to an acute care setting. Protocols for patient treatment are identical in both an Observation Stay and an Acute Care setting for identical injections. • Probability of unexpected outcomes: very low but depends on the drug being administered.

12. Therapeutic, Prophylactic, or Diagnostic Injections • Expectation for rapid clinical change: if a patient receives treatment in an outpatient setting it would be very low otherwise the patient would be admitted to the acute care setting . • Recent changes in technology: smart pumps, medications that are ordered in prefilled single dose syringes such as Lovenox, and the use of telepharmacy to verify all medications delivered to the patient. • Clinical context delivered: higher acuity patients would already be screened out and admitted or transferred to an acute care setting.

13. Protocols CMS has stated that RNs do not have sufficient training to supervise and that protocols “do not give all possibilities for changes.” • Specific protocols exist for the HCPCS codes listed in this presentation. • Carrington Health Center protocols indicate the RN is to “stop” the infusion and contact the provider if a nurse encounters an issue. This ensures a fast response and quick treatment if required. A physician or NPP is always contacted at that point and if the infusion must be stopped a physician or NPP is required to come on site and examine the patient and recommend further treatments if required. • RNs practice within the scope of their licensure with the expectation that they must supervise other nursing staff and be responsible for all care given to a patient that includes using the five rules of medication administration. • Emergencies (most severe would be anaphylaxis) are handled with predetermined medications/anaphylaxis protocols and anaphylaxis kits that are readily available in the outpatient settings. • The higher acuity patients would already be screened out and admitted or transferred to an acute care.

14. Recommendation: Allow general supervision for all HCPCS codes in this presentation, rather than direct supervision switching to general supervision once “stable.”

15. Consequences if direct supervision, rather than general supervision, is required for these HCPCS codes in CAHs: • Inability for patients to receive care locally for simple outpatient procedures • Loss of physicians in rural areas already struggling to obtain physicians to cover direct supervision. • Greatly increased costs to Medicare if patient is admitted to acute care facility for less complex services • Crippling of rural health care delivery

16. Questions?