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CM redesign positions hospital as an ACO
Initiative includes single point of entry
As part of its transition to becoming an accountable care organization, Cheyenne (WY) Regional Medical Center has redesigned its case management model and implemented a transfer center, a single point of entry for all patients whether they are transfers from smaller hospitals, direct admits from provider offices, or patients admitted by emergency department physicians.
"Our mission is to bring patients into the hospital when they need to be here, have them in the appropriate level of care, and ensure that they stay for the right duration and go to the next level of care in a timely manner," says Victoria Choate, RN, BSN, CCM, RN-BC, CCP, PAHM, CPHQ, vice president of performance excellence and chief quality officer for the hospital.
Cheyenne is a small city (60,000) in a sparsely populated state of about half a million residents. Cheyenne Regional Medical Center is the only hospital in the city and covers a wide geographic area as well. The hospital is at 80% capacity most of the time, with 130 to 160 beds occupied each day.
The hospital is part of Cheyenne Accountable Care Organization LLC, a partnership between the hospital, Southeast Wyoming IPA, and WIN Health Partners, a health plan owned jointly by the hospital and the provider group.
Accountable care organizations are patient-centered partnerships between payers and providers and have an emphasis on prevention and care management across the continuum.
"When we made the decision as an organization to become an accountable care organization, we started to think of our patients not as patients but as a population that needed service across the care continuum. We wanted to remain current with expectations by regulators and payers, to prevent unnecessary readmissions, [and] minimize our risk from audits by the recovery audit contractors [RACs]," she says.
Before the redesign, the hospital had an integrated model for case management.
The social workers and RN case managers had separate functions with some cross-over duties.
"Their data collection was focused on transactions, such as how many patients have been reviewed for this and that payer. With the older model, the department missed a real opportunity to document the value of the role of case management in the hospital environment in terms of improving clinical quality and cost savings by managing throughput and patient satisfaction," she says.
In the new model, the nurse case managers are unit-based and are responsible for clinical case management and utilization review. On the medical units, they have a case load of about 24 beds.
"Having case managers unit-based helps them build valuable relationships. We've had case managers who wanted to move to another unit and the staff have expressed their reluctance to lose that case manager," Choate says.
Hours for case managers vary by floors.
"They come in when they know the doctors are most apt to round. The surgical case managers typically work from 6 a.m. to 3 p.m. Case managers on other units may work 8 to 5. Some units are covered until 6 p.m. to provide availability when the physicians are rounding," she says.
The nursing staff facilitate simple discharges. The social work case managers handle complex discharge planning in the unit until 6 p.m. and by telephone until 9 p.m.
"This way, if the physician discharges a patient after 6 p.m., the social workers are able to facilitate the discharge and not keep the patient overnight," she says.
The social workers work with the case managers to meet the psychosocial needs of complex patients, Choate says. They are responsible for roughly twice the number of patients as the nurse case managers.
Both disciplines cover the hospital on weekends.
The first priority of case managers is to review patients who are in observation, starting with those who are nearing the 23rd hour of the stay. They review Medicare patients first every day, then other patients whose payers require daily reviews.
"We determined that Medicare patients should be reviewed first because they are the most vulnerable population, with high rates of chronic disease and readmissions," Choate says.
The hospital is moving toward an integrated model of case management that will interface with all aspects of the accountable care organization, including case management at the health plan and the physician office.
"We now are in the collaborative phase, bringing evidence-based decision-making to the case management process, building relationships with key stakeholders, and defining the metrics needed to ensure value, clinical improvement, financial stewardship, and patient and provider satisfaction," she says.
As part of the redesign, the hospital moved from using InterQual admission criteria to using Milliman Care Guidelines, implementing the guidelines Nov. 1, 2010.
The hospital's transfer center, staffed by case managers and RNs, is the single point of entry for the hospital and functions as the bed control department.
The RNs cover the center 24-7. The case managers currently work from 7 a.m. to 3:30 p.m., but the hospital is expanding their hours to 9 p.m. That time frame will cover the bulk of admissions, Choate says.
The case managers in the transfer center assess every patient that comes in the door, regardless of his or origin, and use Milliman guidelines to make a level-of-care recommendation to the admitting provider.
"We are cross-training the transfer center nurses to be comfortable assessing patients using Milliman. We are looking at using other resources, such as an emergency department nurse, to help support the level of care assignment at the time of admission. We want everyone in the hospital to think about what the evidence says the patient needs and to guide throughput," she says.
The nurses in the transfer center arrange transfers after the social work case manager defines the needs with the attending provider.
The role of the case managers in the transfer center is to screen against Milliman guidelines to determine if the admission is appropriate and the level of care to which the patient should be admitted.
If the patient doesn't meet criteria, the case manager works with the physician and discusses alternatives, such as a skilled nursing facility admission or home with home care.
If the admitting physician insists on an admission, the case manager refers the case to the case management medical director for a second-level review.
"Because we're the only hospital for miles around, as a matter of patient safety, we sometimes have to admit patients who do not meet criteria. They are a priority the next day for the unit case manager who gives Medicare patients a Hospital Issued Notice of Non-coverage [HINN], she says.
As part of the transition to an accountable care organization, the hospital is continuing to look at the most efficient and effective way for the department to function, Choate says.
"The role of the case manager continues to evolve every day. We are reviewing the literature and case management models to determine the best job descriptions for our case managers," she says.
At present, coding and documentation integrity is the responsible of patient financial services, which has dedicated nurse case managers who review the medical records every day to assure that the documentation is complete.
"We are completely revisiting how to manage the core measures to get the compliance where we want it. We have a new core measures team that includes physicians, nurses, and pharmacists who, through process improvement, are working to define how the core measure compliance needs to be handled," she says.
The hospital is considering creating the role of case management assistant, allowing licensed professionals to do what they do best, she says.
The case management team is documenting variances to a timely discharge to determine what steps the hospital needs to take to overcome roadblocks to safely discharging patients, Choate says.
For instance, the team has determined patients may have a longer length of stay because there are not enough skilled nursing beds in the community.
"As we continue to build an accountable care organization, this will help us decide if we need to build a skilled nursing facility or pay for beds so they are available. We don't want our patients in the hospital longer than they need to be," she says.
[For more information, contact Victoria Choate, RN, BSN, CCM, RN-BC, CCP, PAHM, CPHQ, vice president of performance excellence and chief quality officer for Cheyenne Regional Medical Center, e-mail: firstname.lastname@example.org.]