Navigating Social Hospitalizations

Tiffany Ferguson, LMSW, CMAC, ACM
Juliet B. Ugarte Hopkins, MD

In the complex landscape of healthcare, the issue of social hospitalizations presents a challenging puzzle that intertwines patient needs, billing concerns, and discharge regulations. The lines have blurred between the complexity of social needs with medical necessity resulting from the systemic issues in communities unable to provide more appropriate alternatives for their residents. The social admission not only stresses the case management (CM) team who must work a miracle to either find or create a “safe” discharge plan for the patient, but it sheds light on the impact for the entire healthcare team which must manage these patients in the least ideal setting, creating greater stressors on treating physicians, coding and billing, and ultimately patient quality and hospital financial reimbursement. 

Social or custodial hospitalizations refer to instances where patients are admitted to a hospital without medical necessity. These cases typically arise when patients are unable to care for themselves, their families are unwilling or incapable of caring for them, or facilities cannot continue to provide care. Such hospitalizations often stem from complex social issues, however, at times may also be impacting the patient’s chronic medical condition(s).

The consequences of social hospitalizations reverberate across various dimensions of our hospitals and health systems: 

1. Occupational Strain: Emergency departments and inpatient beds become occupied by non-medical cases, limiting availability for patients who genuinely require acute care.
2. Financial Challenges: Medicare, Medicaid, and commercial payers do not easily cover social hospitalizations, resulting in a lack of reimbursement for services provided.
3. Inadequate Services: Patients subjected to social hospitalizations may receive non-intensive therapy, experience social isolation, and lack cognitive engagement, leading to suboptimal care outcomes.
4. Staff Frustration: Healthcare professionals may struggle with the purpose of providing care when medical necessity is absent.

Healthcare providers and case/utilization managers are particularly affected when providers who are trained to address medical needs face difficulties in handling social admissions. Case managers feel the gleaming eyes from administration with the pressure to expedite patient discharges, putting CMs in the role as ‘the bad guy’, making tough decisions for the patient’s best interest. Collectively it is the ambiguity that stresses all for what to do next when the patient is a ‘head in a bed’.  

Weighing the options and levels of care

When determining the course of action for social hospitalizations, options include intervening in the emergency room to keep the patient out of the hospital while attempting to work a timely miracle back into community-based care. An alternate option is to consider the patient to move out of the ED but provide with them with Advanced Beneficiary Notice (ABN), or hospital created notice for patient’s that are not traditional Medicare informing them of the risk of social admission and potential lack of payer coverage for such services. The third option, however, not recommended by your authors, is to issue a pre-admission HINN and admit the patient as an inpatient. In each of these scenarios, the safety and ethical considerations must weigh into the physician decision for the appropriate level of care. 

Understanding that it will take more than SDoH Z code capture to stop the onslaught of social admissions into hospitals, there are things that Physician Advisors and leaders of case management can do to create a proactive approach to alleviate the hospital from what feels like community housing or caregiver respite care. 

Navigating Billing and Patient Rights

Consider connecting with revenue cycle, billing, and the contracting team to evaluate opportunities for coding, and reimbursement coverage for social admissions, at minimum a daily per diem rate to cover the room and board while the care team transitions the patient back into the community. When it comes to billing, make sure there are bed charges available if the care team elects to keep the patient in the ED. 

This will also be a great time to start connecting with your compliance and risk department to make sure the hospital has a considered potential areas of media backlash, appropriate language for patient notices, and considerations for how the hospital defines a ‘safe’ discharge plan. Although, often used as common language, definitions of safety may look different across providers and the hospital should consider waying the ethical implications of keeping a social patient in a hospital bed, while risking the denial of a patient needing medically necessary acute care. 

1. Staff Scripting: Develop clear scripts for case managers and utilization management staff for the various scenarios either at point of entry or when medical care is no longer needed, but the patient has an unideal discharge disposition. 
2. Provider Buy-In: Although the CFO may agree with this plan, the ED physicians may not be on board. Consider the impact of all groups, especially the physician group, so there is a game plan for how social admissions are going to be handled.  
3. Collaboration with Rev Cycle: Establish real-time communication between case managers and billing teams to ensure accurate billing processes, and notice delivery which will involve patient registration/patient access. 
4. Enlist outside help: Consider create means for alternative locations such as setting up single-case agreements with the community facilities who are willing to house patients at a lower cost and better provide for their needs until a longer-term solution is identified by the care team. 

Untangling the complexities of social hospitalizations demands a delicate balance between patient needs, healthcare provider responsibilities, and billing procedures. By establishing a game plan up front while still maintaining necessary compliance and ethical standards, hospitals can address social hospitalizations while upholding financial stability.

Tiffany Ferguson, LMSW, CMAC, ACM is CEO of Phoenix Medical Management, Inc. Juliet B. Ugarte Hopkins, MD is President of the American College of Physician Advisors.