With decreasing healthcare reimbursement, nurse administrators need to aggressively manage care for high-resource users of hospital services to ensure the viability of their healthcare organization. The objective of this study was to (1) investigate frequent Medicare inpatient admission and emergency department users, (2) investigate Medicare day outliers, and (3) examine Medicare reimbursement/ charge ratios.
Although much research has focused on patients who have been readmitted frequently to the hospital, little research has examined patients who are frequent users of both emergency departments and inpatient services.
In this study, all 4,920 elderly Medicare inpatient admissions and emergency department visits for 1 year in a 222-bed general hospital were included. Patient profiles of two categories of high resource users were created.
Results showed the frequent high user group (n = 75), who had six or more combined emergency department and inpatient admissions per year, had cardiac, diabetic, and chronic respiratory conditions, and came to the hospital from their homes. The day outlier profile (n = 148) consisted of older patients who have neoplasms, and respiratory and circulatory diseases. The mean Medicare reimbursement/charge ratio varied for high volume diagnosis-related groups (DRGS.)
From the study, implications include refining case management, monitoring high-resource patients by computer tracking, analyzing high-user trends by several different methods, incorporating many facets of an integrated healthcare delivery into their care, expanding patient, outpatient, and community support programs, and continually monitoring revenue for organizational viability.
Jan V. R. Belcher, PhD, RN, Assistant Professor, College of Nursing and Health, Wright State University, Dayton, Ohio
Betty Alexy, DNSc, RN, Associate Professor, School of Nursing, Old Dominion University, Norfolk, Virginia.