Reducing unnecessary Medicare hospital admissions for chest pain in Arizona and Florida.

Purpose/objectives: Each year in the United States, more than 4.4 million patients with chest pain (DRG 143) present to emergency departments. Many of these admissions do not have documented justification to support an acute inpatient admission. Two Medicare quality improvement organizations identified this as a common theme, and special projects were designed and implemented to reduce the incidence of inappropriate hospital admissions for chest pain in their states (Florida and Arizona). One commonality to both intervention projects was use of the case management protocol (CMP).

Primary Practice Setting(s): Acute care hospitals.

Findings/conclusions: As a result of the special projects, in Florida, there was a 67% reduction in projected admission denials and a 48% overall reduction in chest pain discharges among participating hospitals. In Arizona, the rate of inappropriate 1-day admissions for DRG 143 was reduced 42% from baseline to remeasurement for the participating hospitals; the absolute number of DRG 143 one-day admissions was reduced by 90%. Of the 10 Arizona hospitals that used the case management protocol, 8 met or exceeded the project goals.

Implications For Case Management Practice: 1. Although outpatient observation admission status has been around for many years, there remain confusion and resistance to its use. The definitions of clinical status, level of care, and patient status are not well defined, and choosing the correct pathway for each patient can be complex. This article helps clarify "Observation vs. Inpatient"admission status and details lessons learned in reducing resistance. 2. Use of the case management protocol requires a hospital to define case management roles and responsibilities. This is a critical but often neglected task. 3. Use of case management for determining correct patient status is growing. With new Centers for Medicare & Medicaid Services initiatives, including the recovery audit contractors, case management is a viable solution to maintaining the fiscal health of hospitals.