MISSISSIPPI UNIVERSITY FOR WOMENCollege of Nursing and Speech Language Pathology AdvancedPlacement OptionLeigh Anne Puckett
READTHESE INSTRUCTIONS AND THIS INFORMATION THOROUGHLY.
For the purposes of this NU 471 assignment and the NU 469Teaching/Learning Project, the students will communicate amongthemselves to form self-selected groups of 3-4 individuals. Studentgroups will then select a Medicare qualified diagnosis from a listprovided by faculty. Once the group is secured, one personfrom the group will message Ms. Puckett in Canvas by Friday, June3rd to confirm group members and diagnosisselection. Group member names must be copied and included in themessage to Ms. Puckett so faculty can identify group member names. The selected diagnosis will be applied to all parts of the CaseManagement Assignment in NU 471, and the same diagnosis will beutilized for the NU 469 Teaching/Learning Project.
In NU 471, you will have the opportunity to apply knowledge ofplanning, organizing, directing and controlling by completing thiscase management/clinical outcomes assignment.  The casemanagement process may be applied in numerous settings, but casemanagement is primarily utilized for clients who have complex healthproblems that incur a high cost to the health care system.
To complete this activity, the student must seek additional resourcesand references beyond the textbooks.  It is the student`sresponsibility to locate these resources and references.  Suchadditional references and resources may include evidence-basednursing articles scholarly articles on case/care management orclinical outcomes management and interviews and consultations withcase managers or clinical outcomes managers, medical records staff,coding personnel, quality improvement staff, and others. Networkingwith and interviewing a case manager, clinical outcomes manager,and/or coding personnel will be imperative to completion of thisassignment.
Upon submission of each part of the Case Management Assignment,the total assignment should be submitted each time, so faculty cansee the previously submitted/completed parts of the assignment. Points will be awarded for each section of the Case ManagementAssignment as required for submission on the course calendar.
ALL Student Names: _Sheritta Burt, Sherry Clemons, KameshaMcCarty, Jomeka Smith
PART I –120 points
Article Reviews: 40 points (20 points for each article review)
Select two scholarly or evidence based articles relatedto case management, clinical outcomes, coding, or reimbursementissues. Complete an article review according to MUW School of Nursingguidelines (see Case Management Project Module or RN/BSN Resource forguidelines). If you select an article related to outcomes, pleasechoose an article that is specific to your selected diagnosisotherwise, any topic generally related to case/care management orcoding/reimbursement will be acceptable. Make certain your referencesare correct APA, the purpose is well defined, the summary isexpansive, and the significance to nursing is well stated. Each itemis worth 5 points. Type the review below here:
Tay, E., Thirumoorthy, T., Pang, S., & Lee, H. (2014). Clinicaloutcomes of bacteraemia in cellulitis of the leg. Clinical AndExperimental Dermatology, 39(6), 683-688. doi: 10.111/ced.12366
Purpose of Article:
The purpose of this study is to determine if the occurrence ofbacteremia in cellulitis in a patient has an effect on length ofhospitalization stay, reoccurrence of cellulitis, and mortality in apatient.
Summary of Article:
Blood infections have been associated with high mortality andmorbidity rates. Cellulitis is a condition when there is aninflammation of the dermis and subcutaneous tissue. The condition hasbeen determined to account for approximately 3% of the admissions indistrict hospitals in the United Kingdom (Tay, Thirumoorthy, Pang, &Lee, 2014). The article illustrates the considerable economic andhealthcare burden associated with cellulitis. In their studies,researchers seek to determine incidence of the bacteremia in a caseof cellulitis while assessing the length with which those diagnosedwith the condition have to stay in the hospital. Further, the articlehas a focus on understanding of the rates of recurrence of cellulitisamong patients who had initially been diagnosed with the same. Also,the researchers aim at gaining an understanding of mortality ratesthat are attributed to cellulitis. In gaining insight to the issue,the researchers conduct their studies on a total of two hundred andfourteen patients who had been diagnosed with cellulitis. Theresearchers were analyzing the blood cultures to check forbacteremia. Further, researchers analyzed the duration of time thepatients were hospitalized, the rate at which those treated forcellulitis had a recurrence of the condition, mortality, predisposingfactors to the condition and the comorbidities (Tay, Thirumoorthy,Pang, & Lee, 2014). In their studies, researchers found out thatthe incidence of bacteremia was 10.8%. Further, patients stayedlonger in hospitals having been diagnosed with the condition. Also,scientists found that the recurrence was high if the patients had ahigh bacteremia. However, no difference was imminent regardingpatients with or without the bacteremia. Also, in the studies, it wasdetermined that lymphedema was associated with an increase chance ofthe given patient getting the condition. Other predisposing factorsincluded liver cirrhosis, chronic kidney disease and a total whiteblood cell count greater than 13.5 * 10^6 (Tay, Thirumoorthy, Pang, &Lee, 2014). Overall, the condition has been associated with aprolonged duration of time.
Significance to Nursing Practice:
The insights presented by the researchers are of significance when itcomes to the concept of nursing practice. For example, part of thestudy entailed gaining an understanding of the predisposing factorsassociated with cellulitis. Through the findings of the researchers,it would be possible for nurses to understand how best they canadvise their patients to avoid getting affected by the condition.Further, it would be possible for the nurses to link the conditionwith possible causes. When it comes to the administration oftreatment, it would be possible for the nurses to initiateinterventions that are in line with the findings of the research. Theinformation presented by the researchers is an opportunity for nursesto explain to patients on how best they can avoid the possibility ofgetting the condition.
Frei,C. R., & Daniels, K. R. (2012). Potential complications ofMedicare reimbursement policy regarding health-care-associatedinfections. AmericanJournal Of Health-System Pharmacy,69(3),190-192. doi:10.2146/ajhp110137
Thepurpose of this study is to identify problems with the implementationof the Medicare reimbursement policy.
Healthcare associated infections (HIAs) are one of the leading causes ofdeath in the hospitalized client. Scientists have suggested that HIAsare avoidable. The Deficit Reduction Act of 2005 expanded qualitydata reporting in hospitals and required the Centers for Medicare andMedicaid Services (CMS) to stop paying hospitals for the cost oftreating HAIs if these infections were not present on admission.
Hospitals are reimbursed based onInternational Classification ofDiseases, 9thRevision, and Clinical Modification codessubmitted by the hospital to insures, Including Medicare. These codesinform the insurer which medical conditions were managed and whichprocedures were performed. There are a set of codes for HIAs, and theuse of the codes informs the government which patients developed anHIA during their hospital stay. However, coders are not required tolist a code if the hospital is not seeking reimbursement for thatmedical issue. Therefore coders are justified in omitting those codesfrom the billing data. Subsequently, oftentimes HIAs often go unknownbecause it is not reflected on the billing statement.
This is applicable to current nursing practice because it illustratesthat nurses must always be ethical in the care they provide topatients and in their documentation. Nursing documentation must givean accurate and detailed description of the patient—as the articleproves that moral principles are not always followed in thehealthcare industry and patient billing statements may or may notreflect accurate patient diagnoses. As individuals, we must always dothe right thing despite what others do. Nurses must also alignthemselves with professional organizations that lobby for goodhealthcare policies to help ensure that polices accomplish intendedgoals—as the Medicare reimbursement approach is commendablebut, may have unintended negative consequences.
Create and describe a hypothetical patient scenario based on theassigned diagnosis/complex health problem. For the purpose of thisassignment, the patient has Medicare benefits, so thediagnosis must qualify for Medicare, and the setting isinpatient/acute care setting (hospital). The scenario should include(but not be limited to) the following:
A 67 year old white female presents to theunit from the ER. The patient is alert and oriented times four. Shelives alone at home but her daughter visits daily. The patientvoiced that she noticed that her right and left legs have started tobecome extremely red, warm to the touch, and tender when she touchesthem. She also voiced that they have started to swell. She reportshaving pain while walking. On assessment I note that the right andleft lower areas of her legs are swollen with 3+ pitting edema andthat on palpation the areas feel very warm. She winces in pain whenyou palpate the area. I note as well that the patient’s feet arecool to the touch and you are unable to palpate a pulse. I use aDoppler to find the dorsalis pedis and post tibial pulses which Idocument as faint in both the right and left feet. The patienthistory includes: diabetes, congestive heart failure, peripheralvascular disease and hypertension. An ultrasound was performed on thelower extremities to rule out a deep vein thrombosis in the right andleft legs. This test came back as negative. Pt VS include: HR 80, BP140/96, Temperature 102.4, oxygen saturation 98% on room air, pain 6on 1-10 scale in legs, and RR 18. WBCs 16.5.
Type after each bullet stem.
Age and gender of patient (remember this is Medicare): 5 points
67 year old Caucasian female
Nursing unit or hospital area where nurse first encounters the patient (ER, direct admit to floor, etc.)? 5 points
A 67 y/o white female admitted to the unit from emergencydepartment with complaints of pain and tenderness, and swelling toright and left lower leg. She lives alone and her daughter checks onher daily. She states that he noticed that his legs have becomeextremely red, warm to touch, and tender to touch. She complained ofextreme pain when ambulating, nausea, and vomiting. She presentedwith a fever of 102.4.
Past medical history (create the history and identify comorbidities for this patient)  5 points
Her medical history includes: diabetes, hypertension, peripheralvascular disease, and congestive heart failure.
Subjective data  (information from the patient or family upon admission) 5 points
The patient voiced that she noticed swelling and redness to rightand left lower extremities. She stated that they were warmand tender to touch. She reports having extreme pain while walkingand episodes of nausea and vomiting.
Objective data: document a complete physical assessment and complete review of systems (include specific findings).  Combined subjective and objective data help establish diagnoses and provide data for coding and identifying outcomes.  10 points
The patient identifies that the left and right legs have become red. Further, she notes that they are warm and tender when they are touched. Also, she notes that the legs have started swelling and feels pain when she is walking.
A physical assessment of the patient indicates swelling of the right and the lower areas. The result is 3+ pitting edema. Warmth is felt on the areas that have been palpated and patient winces with pain during the process of palpation. Further, her feet are cool when touched, and difficulties are encountered when it comes to palpation of a pulse. Dorsalis pedis and post tibial pulses are faint in both the left and right feet. Patient has had a history of diabetes, hypertension, congestive heart failure and peripheral vascular disease. Testing results include BP of 140/96, HR 80, Temperature 102.4. 98% oxygen saturation. Pain of 6 on a scale of 1-10. WBCs are 16.5 while RR measured 18.
Identify potential complications and consequences of disease or injury (for prevention and early detection).  5 points
The patient has been determined to have 3+ pitting edema. It is astate where fluid accumulates in intercellular tissues resulting inthe abnormal expansion of the interstitial fluid volume. Theaccumulated fluid arises in a state where the local conditions in thebody disrupt the equilibrium resulting in an increase in thecapillary hydrostatic pressure, an increase in the plasma volume, adecrease in the oncotic pressure, and in extreme cases, lymphaticobstruction. Multiple complications are likely to be encountered withthe identified case of edema. For example, the patient is alreadycomplaining of pain which can be attributed to the swelling. Further,if the situation is not addressed in due time, chances are that shewould not be in a position to walk or much difficulties are likely tobe faced because of the same. Finally, there is a likelihood of thepatient encountering a decrease in the circulation of blood. Theaccumulation of fluid significantly impairs the normal blood flow.Detrimental effects are likely to be encountered with a decline inblood flow since vital organs could lack the supply of nutrientsneeded for normal metabolic activities such as energy production bythe cells.
Also, the patient complains of high fever as attested by the hightemperatures. The effect of the same could be a disruption in thenormal functioning of the body that could worsen if the issue is leftuntreated.
From your assessment, identify any “never events” or “present on arrival” issues (risk for falls, skin integrity, suicide precautions, etc.) or safety issues that should be documented, which will affect revenue/reimbursement.  5 points
Risk for fall r/t pain and edema to right lower extremity
Present on Arrival
Risk for Impaired skin integrity r/t redness and inflammation to lower extremities
Present on Arrival
Acute pain r/t inflammation of subcutaneous tissue
Present on Arrival
Imbalanced nutrition less than body requirements r/t poor food intake.
Identify medical interventions, procedures, diagnostic tests with results, and lab tests complete with results to support the scenario.  5 points (minimum of five for assignment purposes, but you may list all that apply)
The patient is determined to be suffering from edema. The managementof the condition is often directed towards addressing the underlyingcause it is associated with. The patient has an accumulation of fluidin the legs negating the need to introduce a mechanism to eliminatethe obstruction of normal fluid flow.
Blood thinners could be employed as a medical intervention to removethe clot disrupting normal blood flow. The patient has previously hadhypertension and congestive heart failure indicating that normalblood flow may have been interrupted before. Removal of theobstruction resulting in the inability of the blood to efficientlyflow could serve as an appropriate intervention when it comes toaddressing the problem.
Further, the patient has a temperature of 102, indicating presence offever. A medical condition for the same could include use of drugssuch as ibuprofen. The drug serves to reduce the fever beingencountered by the patient. However, the patient can administerself-care for themselves through taking a cool bath or use of cooltowels to reduce the fever.
Also, patient has a BP of 140/96 that could indicate stage 1hypertension. The patient can be subjected to a medical interventionthat includes taking angiotensin-converting enzyme (ACE) inhibitorsand the angiotensin II receptor blockers (ARBs). However, the patientcan have a change in lifestyle including engaging in regular physicalexercises to help in addressing the condition.
What do abnormal diagnostic values indicate? 5 points
Indication of Abnormal Value
Culture of right lower leg drainage
RBC =4.9 trillion cells/L
WBC =16.5 cells/L(Abnormal)
Platelets= 370 billion/L
Inflammation, infection, trauma
Suggests that there is inflammation but does not specify location or the cause
Rates will be increased in the presence of inflammation
H. Nursing Actions: 8 points (1 point for each) -Prioritizethe first four independent nursing actions that should occurwhen the nurse FIRST encounters this patient.  The nursingactions will be reflective of the setting in which the patient isfirst encountered (by you the nurse) as identified in theinpatient scenario. Remember, these are independent nursingactions.  Utilize critical thinking to prioritize the first fourinterventions in this scenario and give rationale for theinterventions.
4 Prioritized Independent Nursing Actions
Rationale for Each Action
Obtain vital signs, Oxygen saturation
To establish baseline medical results
Obtain history of trauma to skin
To identify the life-threatening condition to initiate supportive treatment
Perform complete physical assessment
Inspection and obtaining medical information
Insert IV access
Specimen collection and provides route to administer medications
I.    Interdisciplinary Team for CollaborativeCare:   6 points
Identify 6 team members that could be involved in the patient’scare to improve their outcomes. List the appropriate team member andthe specific patient care outcome for collaborative(multidisciplinary) care of this inpatient. Consider the patientscenario and potential complications that could be experienced bythis patient. Remember to include any health professional teammember affecting this patient’s care or consultations.
Collaborative Care Team Member 0.5 point each
Patient Care Outcomes-Dependent on Diagnosis 0.5 point each
Nurse-provider and coordinator of care
Patient will have dopplerable pulses in lower extremities during hospitalization.-Patient right and left leg will show signs of healing within 48 hours (decrease appearance of redness, swelling, and pain in the affected areas).–Patient will demonstrate how to check his feet and legs for infection and verbalize the importance of doing this often due to his diabetes by discharge..
Patient symptoms will improve with treatment prior to discharge, follow up care will be provided, and appropriate consults for supporting physicians will be made.
PCA (personal care assistant)
Patient will be independently performing daily care activities
Patient will have benefit of gaining support in execution of various tasks while at the same time supporting them emotionally.
Patient will learn to cope with the problem they are encountering through therapy
Plan of care will be discussed and implemented for returning home.
J. Discharge Planning Teaching is an important nursing roleand the length of stay (LOS) is a definitive influence regardingplanned care. 9 points total (3 points each)
1. Describe the discharge planning information that the nurse couldinitiate upon admission and be shared with this patient/family toimprove patient outcomes?  3 points
Discharge planning and teaching begins upon admission. Explain tothe patient and family about the new diagnosis of cellulitis on alevel that they understand and some of the things they can expect tohappen this during this hospital stay. Stress importance of making itto all follow up appointments as they are scheduled. Also teach themwhen they should call the doctor and when to go to the nearestemergency room based on signs and symptoms.
2. Discuss the significance of LOS, acuity index, comorbidities, andallowable days in planning this patient`s care. 3 points
All hospital stays should be limited to the least amount of daysas possible. The longer a patient stays in the hospital the moresusceptible they become to hospital acquired infections. Allowabledays are predetermined based on the diagnosis of the patient.Depending on the patient’s past medical history some are at ahigher risk of developing another infection they did not come intothe hospital with. Typically, a patient in the hospital has lessphysical activity limiting their mobility leading to weakness.
3. In designing a plan of care for this patient, otherspecific additional factors or information are needed,considering this patient is dependent on Medicare coverage. Whatadditional information do you need from the patient/family tocomplete your assessment and begin a plan of care? (For example,additional financial support, resources, functional assessment,learning barriers, special needs, etc.) 3 points
Does the patient qualify for any other insurance programs?
Yes. The patient may need specialized treatment especially when itcomes to dealing with removal of the excess fluids in the body.Because of the same, it could be crucial to have the patient haveaccess to other insurance programs.
Does the patient qualify for prescription assistance programs?
Yes. The patient may need assistance with the use of the hypertensiondrugs.
Will the patient have proper transportation for follow upappointments?
Patient has a daughter who can be requested to facilitatetransportation back home.
Does the patient have any special needs or learning disabilities?
No. Patient has not had a history representative of the same.
Will the patient have family that will be able to spend more timewith her throughout the day?
Yes. Patient has a daughter who checks up on her on a daily basis.
K.    Variances: 3 pointsWhat factors, variables, physical variances, or other considerationswould alter the plan of care for this patient, thus impacting thecase management approach?
It could be essential to consider the financial capability of thepatient when it comes to access of specialized form of treatment. Thepatient may need guidance when it comes to the use of hypertensiondrugs.
Further, it could be essential to consider the adverse effects ofusing different drugs in helping to manage the patient. Suchconsiderations are essential to help protect the patient fromsuffering from cases such as allergies.
Also, patient could need close care. She has a daughter who onlyvisits but does not stay there. It could be crucial to consider howshe can get further care to help improve her condition.
L. Nursing Roles:  4 points
Identify how the nurse impacts the patient outcomes using thefollowing categories. Relate these to your patient.
How this role facilitates case management, outcomes, and reimbursement.
As the caregiver you want to make sure that test and procedures are done in a timely manner as ordered by the physician to help decrease the length of hospital stay.
As the manager you would want to assist with discharge planning needs.
As the teacher you would want to educate the patient and family about the new diagnosis, provide them with the resource information needed and answer any questions to the best of your ability or refer them to the person needed.
As the advocate you advocate for the patient. The patient and family depends on the nurse to convey their needs to the physician and they expect you to care for them to the best of your ability and have them at their best interest.
MISSISSIPPIUNIVERSITY FOR WOMEN College of Nursing and SpeechLanguage Pathology Advanced Placement Option
ALL Student Names:_
PART II –120 points
Interview 30 points Case management is a collaborative effort primary to this effort is the caregiver (RN) and/ or the case manager. It is important to understand the role of the case manager or quality assurance manager. Interview a case manager, outcomes manger, quality assurance manager, and/or coder to facilitate completion of this assignment. It is imperative that you include the following contact information for each interview for confirmation purposes only one interview is required, but you may have to network with other health care personnel to retrieve information.
Name of personinterviewed:
Title of person:
Name of facility:
Email address ofperson interviewed:
Workphone of person interviewed:
Write a briefnarrative of the interview(s) and include roles, responsibilities,and other general information gleaned from the interview(s):
List the top 5 Diagnosis Related Groups (DRGs) in one of the facilities where you interviewed or the top 5 DRGs in the state where you live. 10 points (2 points each).
O.    Diagnosis ICD: 10 Codes  Assignthis patient the ICD: 10 code for the principal diagnosis and namethe diagnosis. 5 points
P.    Procedural ICD: 10 or CPT Codes
Assign this patient the ICD: 10 procedural codes or CPT codes for aminimum of five inpatient procedures or diagnostictests. 20 points
The purpose of this activity is to acquaint the student with theprocess of coding to capture reimbursement which requires properdocumentation by nursing and medical personnel. Also, it is toacquaint the student with all the coding and data entry requirementsfor various tests, procedures, and laboratory studies.  The codeassigned to the test determines the amount reimbursed.
Proper documentation is mandatory to capture revenue.  List onediagnosis (symptom) per study which must be documented in thepatient`s chart to qualify this study for reimbursementconsideration.
ICD:10 or CPT Code
2 points each
Symptom for Reimbursement
2 points each
Q.    DRG Code:   5 points
Assign this patient a DRG code (name the diagnosis for this code,also) in accordance with the principal diagnosis. Explain yourrationale.  Remember to consider comorbidities and anyinformation that would facilitate assigning this patient a proper DRGcode to capture revenue.
R.    Reimbursement:  5 points
Identify the Medicare reimbursement amount for this DRG. S. Cost Analysis:  3 points
Describe this facility`s process for determining patient expenses orperforming a cost analysis for any patient. No actual costfigures are needed, just describe the process for determiningcost for all patients. Also, be sure to include the process forcapturing DRG reimbursement.  Cost must be established in orderfor each facility to compare cost/reimbursement data. (Basically, howdoes this facility determine how much it costs to care for anypatient? Were costs reimbursed? How does this facility know whichDRGs are not being adequately reimbursed?)
T.    Charges:  10 points
Be mindful that all the facility expenses are supported through therevenue producing departments. Using no specific prices or codes,identify the name of the revenue producing department or servicearea. Be mindful of nonrevenue producing areas that still presentexpense to the facility and must be paid from revenue producingservices. List indirect costs or non-revenue producing departments.
List 5 revenue producing departments/areas of any hospital 5 points
List 10 non-revenue producing departments/areas of any hospital 5 points (.5 each)
U. Revenue:   4 points
From information that was available to you regarding DRGreimbursement and cost analysis, "guess-ti-mate" ifthe reimbursement from Medicare is projected to be adequate to coverall charges and costs related to this patient`s care.  YES or NO1 point
Explain your response.  (The purpose ofthis activity is to emphasize the relation between cost of care andfactors that affect reimbursement). 3 points
V.    Standards of Care/Evidence Based Practice: 13 points
Clinical pathways (CP), plan of care models (POC), multidisciplinaryaction plans (MAP), clinical practice guidelines (CPG), or careguides (all synonymous terms) are sometimes utilized by hospitals tomanage and evaluate client care. There is not one set standard ofpractices. The standards may vary depending on the region ororganization which published the guidelines. 1. Consideringthis patient`s diagnosis, identify a standard of care or protocolpublished by a medical organization such as American HeartAssociation, American Thoracic Society, National Institute of Health,etc., which serve as a guideline for patient care. http://www.guideline.gov (Evidence Base Practice on course menu).http://www.guideline.gov/browse/xrefnqmc.aspxProvide an on-lineaddress or a copy of the first page of the medical guidelines withstandards specific for the patient`s diagnosis. 3 points
2. Analyze the care guide in relation to the standards of care. Identify a minimum of two actions in the guide and discuss howthe action facilitates case management or relates to the concepts ofcare/case management. 10 points (5 points each)
W.    Resources and Referrals: 4 points
What additional resources, referrals or agencies may be needed toassist this patient upon discharge? List two services which may bebeneficial to this patient upon discharge 2 points Statewhether each of these services is covered by Medicare?  2points
X.  Indigent Care Cost: 3 points
Describe how this facility or other facilities approach issuesrelated to indigent care cost. Basically, how do facilities offset orprocess indigent care cost?
List a minimum of three programs and/or options that can be utilized by any facility to offset indigent care cost not absorbed by Medicare or other reimbursement?
Y. Professional Accountability: 8 points
1. From your understanding of case/care management, reimbursement,and quality assurance, select the most important nursing actionthat would improve health care in the facility where you work (physical assessment and direct patient care documentation ofinformation improving communication among the health care team aboutpatient care improving patient teaching and patient compliance,etc.). 3 points
2. Explain why you identified this as the most importantconsideration? 2 points
3. What action(s) will you take to initiate the needed change andmeet your professional accountability? 3 points
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