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Cancer hospital assigns UR to dedicated nurses
As part of its efforts to increase patient satisfaction and reduce length of stay, City of Hope reorganized its case management department, assigning case managers by unit and assigning all utilization review activities to a dedicated staff of registered nurses.
"Our hospital is a National Cancer Institute-designated Comprehensive Cancer Center, which means that many of our patients require specialized care from a number of clinicians," says Mary Scott, RN, MS, director for case management and clinical practice education at the Duarte, CA, facility. "By reorganizing, we wanted to become more efficient but continue to provide patients with everything they need related to care progression during the course of treatment."
Patients at City of Hope have an average length of stay (LOS) of 9.5 days because their care needs are so complicated, Scott says. As part of its efforts to reduce LOS, the hospital administration brought in a consultant to help to help determine how to align the department to optimize the case managers' time and provide optimum patient care.
Before the redesign, case managers were aligned by physician and physician group. Now they are assigned by units and receive specialized training on coordinating care for patients on their unit. There are case managers on each of the two bone marrow transplant units and a separate case manager for pediatric patients. The other case managers are assigned to medical oncology and surgical oncology units. (For details on the case managers' day-to-day activities, see related article below.) "Having the case managers assigned to the point-of-care provides better continuity of care," Scott says.
The redesign task force decided to completely remove utilization review (UR) responsibilities from case managers and to assign them to a focused UR staff. The nurses who conduct UR report to the quality improvement team and case management leadership.
The hospital chose to continue to use RNs for utilization review because the care of cancer patients often is extremely complicated, Scott says. They work with the physician advisor and the hospital's off-site physician advisor service when questions about medical necessity arise. "It takes someone with a lot of clinical knowledge to review the medical records of our patients and to make the case for medical necessity," she says.
Coders are assigned to each hospital unit and perform concurrent coding. They interact with the case managers frequently, and plans call for them to round with the physicians, Scott says. "The utilization review piece of the reorganization has gone quite well," she says. "Our denial rates are very low, and our denial days are low."
Assigning UR duties to other clinicians allows case managers to spend more time at the bedside with patients and families and to be more proactive in planning for discharge, Scott says. Patients often have multiple admissions, multiple treatment processes, including clinical trials or one-day procedures. Many spend time in the ICU.
"We see patients in many sets of circumstances," Scott says. "Once they come into the system, they are likely to stay in our system and receive services over a long time. The case managers follow them as they transition from one level of care to another."
As part of their efforts to reduce LOS, hospital administrators are reviewing the files of patients whose stay was two times greater than the geometric mean length of stay and looking at roadblocks to discharge and ways to decrease the stay.
The case managers have goals-of-care conferences with the treating physicians when patients have a length of stay that is longer than expected. "We look at the treatment plan and what we need to do to get the patient ready for discharge," Scott says. "Most of the time when patients have a long length of stay, it's because it wouldn't be safe for them to go home and it takes time to find a post-acute placement for them."
As more California residents have become eligible in recent years for California's public health insurance program, the difficulty in post-acute placements has increased because a lot of providers won't take MediCal patients, she adds. Medication management often impacts length of stay and readmissions, Scott adds. "We routinely send people home on 20 or more medications, and it takes a while to get the medication adjusted in the hospital," she says. "Then when they get home, it's difficult to manage."
The case managers are re-evaluating all readmissions to determine why the patient came back and what could have been doing to eliminate the readmission. "We want to know if the patient was sent home too soon or is having symptom management issues we didn't address, if the readmission is because of disease progression, or if they aren't able to manage their pain or other symptoms at home," Scott says.
The team has determined that many patients are readmitted because of medication management issues at home. Other times, they didn't tell the staff how much pain they were in because they were so eager to go home. Then they come back to the hospital because they can't control their pain, Scott says. "We're looking at the cause and the nature of readmissions and what we can do to prevent them," she says. "It's traumatic for cancer patients to come back to the hospital because they would much rather be at home with family."
The cancer challenge: Coordinate care
At City of Hope National in Duarte, CA, case managers (CMs) collaborate with clinical nurse specialists to manage the care of complex cancer patients.
The hospital has 177 inpatient beds and typically is at about 75% capacity. About 40% of patients are involved in clinical trials. Case managers typically have a case load of 15 to 18 patients.
The CMs round each day with the clinical nurse specialists on the unit and review the charts of all new patients. The clinicians look at the patient's disease process, complications, symptom management, and skin issues. They make sure that the documentation in the medical record has captured all the patient's symptoms. The case managers also attend multidisciplinary rounds led by the physicians and work with theclinical nurse specialists to set goals of care for the day. They include other clinical staff, patients, and family members in the discussion.
The case managers assess patients for the reason of admission and work with the utilization review nurses to make sure the patient continues to meet medical necessity criteria. They assess the patient's psycho-social needs, home situation, and short-term and long-term treatment plans. They also make sure the patient is moving through the hospital continuum to discharge. They hold goals-of-care conferences with the unit staff, the ancillary staff, and the family. Case managers also work with patients and family members to help them make decision for palliative care and end of life.