E991 WATERBU RY HOSPITAL 64 Robbin? Stu-er (T 0070? Patient Notice of OBSERVATION Status Your doctor has ordered for this hospital stay. OBSERVATION is a brief hospital OUTPATIENT stay focused on the main reason you came to the hospital for medical care. OBSERVATION allows your doctors to continue testing to ?nd the cause of your or to provide treatment that can be completed in a short time period. Usually, your doctor can determine whether to admit or discharge within 24 hours. OBSERVATION may affect Medicare, Medicaid, or private insurance coverage. If you have Medicare, being in Observation means: 0 Medicare Part is responsible for payment of outpatient hospital services. 0 You are responsible for your yearly Part deductible and co-insurance requirements. a You may be liable for some other charges on your bill such as medications and pharmaceutical supplies if they are not covered under your Part Medicare or if you do not have Part Medicare. 0 Your observation stay does NOT count toward the three day ?qualifying inpatient hospital stay? requirement for Medicare coverage in a Skilled Nursing Facility (SNF). 0 If you do not have a three day inpatient hospital stay and need care after discharge, ask about care in another setting as home health care or if any other programs (Medicaid or Veterans? bene?ts) can cover your SNF care. If you have a Commercial or Managed Medicare insurance: 0 You are responsible for any out-of?pocket expenses, such as co?payments, deductibles and non-covered services in accordance with your speci?c insurance plan. 0 Please contact your health insurance provider for coverage details or call the Of?ce of the Healthcare Advocate (1-866?466?4446) to better understand placement in observation status with your insurance. If you have Medicaid insurance: 0 As per State of Connecticut regulation, you are required to receive notice of your observation status. You are not responsible for out of pocket expenses. Who can I contact if I have questions or concerns? The Case Management team is here to help you. Please contact your case manager/social worker or call the Case Management Department at 203-573-7260. For more detailed information about how Medicare covers hospital services, visit Medicare.gov/publications to read the ?Medicare You? handbook. You can also call 1-800- MEDICARE TTY users should call 1-877?486-2048. Please sign and date that you have received and understand this notice. Patient Signature Date/Time Authorized Representative Signature Date/ Time Outpatient Observation is considered an hourly continua- tion ofyour outpatient visit, even though your care, evalua? tion and treatment may be provided in the privacy and comfort of a hospital room. The advantage of this is that the- outpatient evaluation period may be ektended in a more comfortable environment. Afulliinpatient admission may be able to be avoided. You will be discharged once your have been evaluated. This may occur any time during the day or night. Please make sure you have made necessary arrangements for your transportation home. You may experience some of the following activities: CONSULTS Your physician may request a specialist (consult) to examine you. This may occur at any time during your stay. TESTS An ECG (electrocardiogram) may be taken. Blood may be drawn fortesting. A chest x-ray may also be done. VITAL SIGNS ~Temperature, bio'od pressure and pulse may be checked as ordered by your physician. TREATMENTS an intravenous (IV) device may be placed for medications and fluids. You may receive oxygen therapy. You may be placed on a telemetry monitor to follow your heart rate and MEDICATIONS - Tell your nurse if you are experiencing any pain or discomfort. Effective pain management is important. ACTIVITY Your activity may be limited as ordered by your physician. A physical therapy consult may be ordered. DIET You maybe placed on a special diet as ordered by your physician. DISCHARGE PLAN You may be discharged today if. clinically stable and will follow up with your physician as an outpatient. Further testing may be ordered. A social worker or nurse case manager may talk with you about your needs for home. TEACHING Your physician and nurse will review your plan of care with you. You may be instruoted on diet, activity, med- ications and procedures. WHAT IS. QUTPATIENT Observatibh is a billing category permitting patients to stay in the hospital for a short time with problems that do not'IqL'Ialify for an inpatient hospital stay. WHAT IS THE DIFFERENCE IN Observation is billed under outpatient services (such as Medicare Part B). You may be responsible for a c'o-pay, deductible or co?insurance. Hospital admission is billed under inpatient services (such as Medicare Part A). Also, Medicare does not cover medications thatyou may routinely take at homeon a regular/daily basis that are given to you during your outpatient observation stay. You may wish to have your own medications brought in from home. They must be in their original labeled containers and, for safety reasons, no controlled substances such as pain medication or sleeping pills are allowed. Please tell your nurse ifyou have your medications with you or if you choose to have them?brought in. Your medications will be securely stored by the Hospital. WHAT KIND OF PROBLEMS DO PEOPLE HAVE THAT MAKE OBSERVATION Observation can be used for problems that are expected to be treated or evaluated in less than 24 hours, such as chest pain, headache, nausea, vomiting, kidney stones, and some breathing problems. - WHAT HAPPENS IE MY PHYSICIAN DECIDES MY CONDITION REQUIRES ACUTE Your physician mustwrite an orderto convertyour outpa- tient observation to an inpatient admission. DOES OBSERVATION QUALIFY ME FOR MEDICARE SKILLED NURSING EACILITY No. Your observation stay does not count to qualify for Medibare skilled nursing facility benefits. Instead, a three day inpatient stay is required. Any questions you may have regarding these guidelines or any aspect of your care should be directed to your physician or nurse. WATERBU RY HOSPITAL 64 Robbins Street - Waterbury, CT 06708 (203) 573.6000 WATERBU RY HOSPITAL A be if AS AN OBSERVATION PATIENT Outpatient Observation