All Entries in the "Patient Flow/Throughput" Category

Promoting efficient use of resources and appropriate hospitalization length of stay to physicians, a different approach

Physicians sometimes acquiesce to family wishes and desires and admit a patient for “social” reasons. On the other hand, a physician may keep a patient in the hospital an extra day because the patient expresses a desire to stay just “one more day.” These unnecessary, avoidable hospital days have a material effect on potential revenue loss for the hospital through denied days or denied hospital stays by third party payers.

A major challenge in motivating physicians to move the patient along the continuum is the disconnect between prudent hospital fiscal management and the practice patterns of physicians. The physician generally receives payment for his evaluation and management services regardless of whether the hospital is paid or denied for the patient care.

However, change is on the horizon. Medicare is currently considering provisions that will promote efficiency in the practice of medicine. Medicare and other third party payers are also committed to transitioning from physician payment based strictly on volume to payment based upon the relationship between quality, costs, and outcome. The efficiency and effectiveness of a physician’s practice of medicine will determine the physician’s financial welfare and business success.

Evidence of this impending change in reimbursement can be found in the General Accountability Office’s (GAO) report entitled “Per Capita Method Can Be Used to Profile Physicians and Provide Feedback on Resource Use.”  This report is a must read. In essence the report concluded that it is feasible to use Medicare claims data to profile physicians on resource use, taking into account patient acuity through risk adjustment methodologies.

The report examined the following:

• The extent to which physicians in selected specialties show stable practice patterns and how beneficiary utilization of services varies by physician resource use level
• The factors to consider in developing feedback reports on physicians’ performance, including per capita resource use
• The extent to which feedback reports may influence physician behavior

The GAO focused on four medical specialties (cardiology, diagnostic radiology, internal medicine, and orthopedic surgery) and chose four metropolitan areas (Miami, Phoenix, Pittsburgh, and Sacramento).

Take this oppurtunity to educate physicians about the possible changes in the reimbursement model

The message is out!

Now is the time for case managers to become familiar with these eventual changes to the healthcare reimbursement model from a physician and a hospital perspective. This reimbursement model transition will not only drive out waste in the practice of medicine. It will also drive and promote a collaborative approach to healthcare delivery by using financial incentives.

Case managers should educate physicians on the need to collaborate with case management to move the patient along the continuum efficiently because physicians will receive reduced reimbursement for excessive resources.

Let the education begin.

Understanding the insurance company case manager’s goals can help hospital case managers

While discussing a hospital admission with a case manager employed by a well-recognized national third-party payer, I learned of an interesting revelation that case managers may wish to take note of.

Each insurer-employed case manager is charged with meeting a monthly average length of stay goal set by the individual hospital as well as the aggregate hospital. The insurance case manager receives a weekly report of cases that achieved average length of stay compared to individually-assigned average length of stay goals and objectives. To this end, the case manager knows at any given time where he or she stands in regards to meeting the assigned goals for hospital length of stay.

This insurance company case manager informed me that he is reminded on a regular basis of the ramifications of not meeting the established monthly length of stay goals. In extreme situations, insurance companies will terminate case managers that do not meet objectives.

Depending on the time of month and how the insurance company’s case manager is faring, hospital case managers can expect different volumes of cases designated for medical director review and potential medical necessity denial. There exists a certain realism that insurer case managers and medical directors may err on the side of conservatism when using Interqual or Millman care guidelines and clinical judgment to determine denial of inpatient stays. The bottom line is hospital case managers will need to take inventory of their communication skills and core competencies, including drafting of effective, succinct denial appeal letters—if the hospital charges him or her with doing so as one of their duties.

In this context, hospital case managers should track and trend denials communicated by insurer case managers and understand these case managers need to achieve pre-established average monthly length of stay goals. Hospital case managers must prepare for increased inpatient stay denials given the current economic climate of private health insurers, decreased member covered lives, and resulting decrease in health insurance premium income. Increased medical loss ratios and the number of uninsured and underinsured patients seeking care through the emergency room with subsequent need for inpatient admission can also add to the number of denials.

I am certainly not advocating for case managers assuming additional work. At many hospitals, the administration assigns new tasks and assignments to case managers with the rationale being case managers already “review the record” and thus have the time to take on new responsibilities. Unfortunately, the case management function has become so convoluted that case managers find themselves regularly performing duties that questionably contribute to the role of case management. However, I am advocating for their development and reinforcement of core competencies and skill sets in the art of “forceful” communication and negotiation.

Identifying emergency department regulars can improve throughput

It would be safe to say that every emergency department (ED) sees a fair share of “frequent fliers” or those patients who seem to use the ED as an alternative to other healthcare resources in the community. Knowing “the players” or the clientele of the ED can help an ED case manager address issues that affect throughput.

In the past year, we at University Hospital, Upstate Medical Center in Syracuse, NY have put together a pilot program, patterned after programs we have seen in other hospitals. The hospital generated a list of frequent fliers in the ED during the previous six month period. We identified a group of patients who not only frequent the ED but also have primary care providers within the same hospital system. We used a team approach involving case managers and social workers in the outpatient setting, to address any barriers in the patients’ lives that may cause him to use the emergency department rather than the primary care office.

The expectation was that a social worker or case manager would see the patient each time one of theses patients presented to the ED or the outpatient setting. The social worker would document the reasons for the visit as well as any interventions in a shared file in the computer. We were all able to access that information daily, and keep tabs on the progress of each patient.

The goal is not to keep patients from emergency care. Sometimes those patients presented to the ED with legitimate emergencies, but often times a different setting would have been more appropriate. In the first six months we were able to decrease the number of ED visits in all the identified patients, and we saw an increase in the number of attended visits with their primary care providers. When the hospital generated list of frequent fliers in the next six month period, over half of the original patients were no longer on the list.

I believe that the ED case manager is a crucial part of the throughput process, and knowing the clientele can only enhance the productivity and efficiency in the ED.

One bad run-in shouldn’t define entire field of case management

Editor’s Note: I came across this letter to the editor that Nancy Sullivan, Director Case Management Massachusetts General Hospital Boston, submitted to the Boston Globe in response to an op-ed column that spoke negatively about case managers. I would like to thank Nancy Sullivan for allowing her letter to also appear on the Case Management Mentor blog.

In her op-ed “The ‘quicker and sicker’ exit strategy’’ (July 30) Deborah Schuss describes her family’s negative – and indeed, unacceptable – encounter with a case manager. One patient’s bad experience, however, should not define an entire field.

As trained and experienced nurses, social workers, and other health professionals, case managers work diligently and compassionately to ensure a safe transition for patients from the hospital to the next setting of care or home. Case managers serve as trusted guides during a period of uncertainty and change, helping families sort out details of ongoing care, and arranging for services after discharge.

As essential members of the patient care team, case managers advocate for the patient and family as they collaborate with physicians, nurses, and others. And while case managers help ensure that care is delivered in a timely and cost-effective manner, their decisions are driven by what is in the patient’s best interest.

I am privileged to witness each day the impact of case managers. One grateful patient wrote that his case manager “went out of her way to do detailed planning about my discharge, checked in with me regularly, was patient with all the questions I had, and reached out to my wife in addition to myself.’’ A family member expressed deep appreciation to a case manager who had spent extraordinary time arranging medical care in Florida so that a terminally ill young mother could travel to Walt Disney World with her children.

These are the case managers I know – true representatives of a profession I am proud to be part of.

Nancy Sullivan
Director Case management Massachusetts General Hospital Boston

Reduce Readmissions: Strategies to Improve Transitions of Care

As the population ages and more people develop chronic illnesses, healthcare professionals are challenged to balance patient needs and the bottom line with the government’s goals to reduce readmissions and improve quality.

Medication errors, missing or incomplete medical record documentation, and human errors that occur when patients fail to understand care requirements are just a few of the problems that can cause unnecessary readmissions. But by educating patients on their conditions prior to discharge—whether to home, a skilled nursing or other facility—and by taking simple steps post-discharge, providers can mitigate the problem.

To that end, HCPro will be hosting a live audio conference, “Reduce Readmissions: Strategies to Improve Transitions of Care,” on September 23.

This program taps the expertise of staff members Karen Mauro, LMSW, ACM, and Christina Pavetto Bond, MS, FACHE, of the Crouse Hospital of Syracuse, NY, who grew their comprehensive program in a nationally recognized model of care coordination.  They will show you how to audit and analyze your readmission data, provide tools to help you develop processes to reduce readmissions, and explain ways to reduce the likelihood of readmissions through pre- and post-discharge education. You’ll also learn valuable tips for effective communication with other providers and levels of care (e.g., primary care physicians, SNFs, and home health).

For more information on how you can reduce readmissions at your facility, visit HCMarketplace.com.

Do you use Milliman?

We are looking for case management departments that use Milliman Care Guidelines for a future project. If your facility uses Milliman, please get in touch with me.

Ben Amirault
bamirault@hcpro.com
781-639-1872 x3934

ER case managers must have special skills

A nurse case manager is a definite asset in the emergency room (ER).  An ER case manager benefits the patients, the staff, and the hospital.  The role is multi-faceted and requires superior skills in:

• Quality
• Education
• Communication
• Customer service
• Negotiation
• Creativity
• Risk management
• Knowledge and understanding of insurance requirements and regulatory mandates

It also requires an ability to interact with patients, families, insurance representatives, and caregivers both in the ER and those who are treating the patients in the out-patient arena.

Visits to the ER may have one of several outcomes. Usually, the patient is treated and discharged home with a plan or the patient is admitted to the hospital. It is here that the ER case manager can be most effective to improve the quality of care and prevent readmissions to the ER.

An ER case manager can ensure that each patient who is discharged from the ER has an appropriate discharge plan that is viable and appropriate to assist the patient in recovering and maintaining their health.  A case manager is an expert in confirming the patient can afford any prescriptions provided , is able to be compliant with recommended follow-up visits with  specialists and can assist the patient in connecting with a primary care physician. The nurse case manager can be instrumental in  working with the patient  and their support system to make sure that they understand and have the interest and ability to be compliant with the discharge instructions.

The case manager can enhance the care provided by a busy ER nurse and physician  by assessing situations and family dynamics, listening to the patient and helping them understand the rationale for various tests and the time needed to interpret results. The case manager can assist the ER nurse with patient education and  providing information necessary to maximize  the patient’s health status.

The case manager can also benefit the hospital by working with both ER physicians and admitting physicians to ensure that all acute care admissions meet medical necessity and are admitted to the appropriate level of care.  The case manager can assist with transfers to alternative levels of care such as skilled nursing or rehab when patients do not meet criteria for acute care but are unsafe to return home.  The case manager can arrange home healthcare, physical  and occupational therapy or other appropriate services to help a patient maintain their independence in the home.

Case managers are an integral part of the ER team to improve the quality of care and help maintain fiscal responsibility for resources both in the ER and on the hospital admitting units. Case managers coordinate care and provide patients will all the tools necessary to improve their quality of life and feel their best within any limits of their illness or disability.

Safe discharge plans for the uninsured

What about those hospital discharges?

Who should be doing the discharge planning and who should be working with the patients and families to make sure the goals set for the patient are being achieved? Who is developing the discharge plan? These are all great and very important questions. Discharge planning should begin as soon as the patient sets a foot inside the hospital, whether that is just to the emergency room or is placed as an observation patient or inpatient.

This is another great reason for the admission case management model. The admission case manager begins the discharge assessment right at the time the patient is either placed in an observation or inpatient status. If the patient is discharged from the emergency room, our social worker works with the emergency room staff, patient, and/or families for appropriate discharge planning.

The seven day a week admission case management model at my hospital is guided by Imogene King’s Theory of Goal Attainment. This theory of goal attainment implies that nursing is to help people achieve, maintain or restore health through the mutual setting of goals (Hood & Leddy, 2006). The nurse and/or social worker and the patient come to agreement on a mutual goal to achieve; this brings the patient to the forefront and the most important being. There is interaction of the nurse/social worker and the patient in the appropriate environment that is most conducive of achieving the goal. Once the goal is agreed upon and set, the next step is defining what steps will be taken to reach the desired goal. Case management as it evolved became a process of assessment of patient needs (goal setting with the patient and or family), planning of care, arranging resources of services and ongoing coordination and evaluation of the care being provided.

Our model is successful because of teamwork. Our case managers and social workers work together with the patient and families as well as the other hospital disciplines, through interdisciplinary rounds to ensure that everyone is working toward the same goal for discharge.

Discharge is more than getting the patient out of the hospital door. It is making sure that the patient is going to a safe, agreed upon place with the appropriate resources available and in place. Successful discharges reduce those unwanted readmissions.

Reference:

Hood, L. J. & Leddy, S. K., (2006). Conceptual bases of professional nursing, (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

What do hospital case managers do, anyway?

This is a question frequently asked by patients, family members, physicians, and other members of the medical staff.

Many people think that case managers are discharge planners, and that the only time a patient needs a case manager is when he or she has discharge needs. Case management is much more than that. It is important that we make sure that, not only do patients and families know what case management is, but that the nursing staff members know also.

Case managers work in forces behind the scenes, much like the crowd of people in the Verizon commercials. Case management is a hidden resource for patients. Often, the case managers work in the trenches, with their heads in charts, communicating with an interdisciplinary team of healthcare professionals to make sure that the patient is moving smoothly through the continuum of care, and there are no delays or detours in their care. This is usually an unknown aspect of case management.

Hospital personnel and the public need to be aware that case managers are advocates for all patients; they ensure that their healthcare facility and professionals are doing what is truly right for the patient, in the right setting, receiving the most appropriate care, and in the most cost-effective manner. Case management follows the patient’s plan of care to make sure that it is appropriate and timely, that their hospital admission status is appropriate, that their discharge planning is initiated, and that goals are set to meet the discharge plan. It is imperative that the case manager build a relationship with the patient and their families in order to reach a mutual goal of discharge.

It is also important for the bedside nurses to know that case managers are an excellent resource for them in planning the patients’ care and goals. One thing I did at our institution while we were redesigning our case management model was to do a mandatory in-service to nursing staff on how case management affects not only patient outcomes, but the financial outcomes for hospitals.

At our institution this year, we included a station on case management and interdisciplinary rounds at the nursing annual competency testing. Case management had a display booth with information about what case management is and the importance of interdisciplinary rounds. We also had a test for the nurses to complete. The comments we received from staff were very interesting.

Does your institution do anything like this? Are you confident that nursing staff members truly understand what case management is?

And one more important question: Do your physicians really know what case management is?