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CM redesign reduces LOS, increases case mix index
Strategies include standardizing program, beefing up technology
By redesigning its case management program and beefing up technology, Saint Thomas Health Services reduced the average length of stay systemwide by 0.20 days and saved more than $6 million in just two years.
"For the three or four years prior to the redesign, we saw the length of stay increase each year, almost like a stair step going up. Since we launched the redesign, the graph looks like a stair step going down," says Elizabeth Lemons, RN, MBA, CPHQ, vice president of clinical effectiveness for the four-hospital, faith-based health care system based in Nashville, TN.
At the same time, the hospital system's case mix index rose, an improvement Lemons attributes to the documentation specialist program and educating the case managers to work with the physicians to improve documentation.
The reorganization was launched about three years ago, after the health care system hired an outside vendor to assess its operations for opportunities for improvement systemwide, Lemons says.
The case management team spent nine months in the fall of 2006 and early 2007 designing the program. The hospital system went live with its model in July 2007.
"We were a fairly young system and wanted to identify ways to improve and increase quality while driving down costs. From a case management standpoint, we took the opportunity to look at best practices in the field and how the case management delivery model was configured," Lemons adds.
The first step was to put case management, now called care management, under the quality umbrella to create more continuity in patient care and to support physicians in managing patients through the acute care stay.
In addition, the hospital system standardized case management programs in the three largest hospitals in the system — Baptist Hospital and Saint Thomas Hospital in Nashville and Middle Tennessee Medical Center in Murfreesboro, TN.
The care management team includes case managers, utilization managers, social workers, and resource center associates who facilitate the discharge of patients with less complex post-acute needs.
Before starting the project, the reorganization team analyzed the system and determined that on the front end of the admission, the case management department was strong when it came to utilization management and working with payers.
However, when it came to discharging patients, the hospital was taking a reactive approach.
"After the physicians wrote the discharge orders, we had social workers on every floor who spent the entire day on the telephone trying to find a placement for the patient," she says.
The Nashville and Middle Tennessee areas do not have an adequate supply of nursing home beds, and in reality, the social workers were competing with each other for beds, Lemons adds.
"We were getting the business aspect done and getting the patient discharged, but we weren't coordinating with the physicians as well as possible. This gap created a real opportunity for improvement," she says.
The redesign team also determined that the department was short-staffed.
"Instead of cutting staff to save money, we found we had to put resources into it to reduce the length of stay, ultimately saving money. We hired 19 FTEs for the three large hospitals in the system and shifted around the front-end business process," she says.
The team created a job description for a professional case manager who works closely with the physician group from admission to discharge.
"Most of the case managers are RNs, but we do accept others who have the skills. Our model requires that case managers have a clinical background and skill set. They have to be business-savvy and understand reimbursement," Lemons says.
For instance, pharmacists and respiratory therapists meet the requirement for case managers. Some social workers who have a master's degree also work as case managers.
Most of the case managers are assigned by physician group. The exception is at Baptist Hospital, which has 683 beds in several contiguous buildings. At that hospital, some are aligned by physician group and others are geographically assigned.
For instance, case managers are assigned to the cardiac service, the ICU, and the step-down unit. Units where patients have complex social needs also have a separate master's-prepared social worker.
CMs drive care
The case manager drives the care, the daily plan for the patient, and the plan for the stay.
"The case manager is one of the first to arrive on the scene when a new patient is admitted. Their role is to get the patient in the right admission status, to complete an assessment early in the admissions process, and to determine the patient's discharge needs," she says.
Once they get the patient in the proper status, the case managers begin the discharge planning process.
"They look at the likely disease course, the expected length of stay, and how complex the discharge will be. They work closely with the nurse and the physician along the course of the patient stay," Lemons says.
The case managers have a 15-20 minute huddle with the hospitalists each day. They look at the patient list, identify which patients are ready for discharge and which are likely to be discharged within two days, and make sure the discharge plan is in place.
The case managers are assisted by resource center associates, most of whom are bachelor's-prepared social workers, and facilitate the discharge needs of patients with less complex discharge needs.
When patients have complex discharge needs, case managers make a consultation with the master's-prepared social workers and work with them to get the patients to the next level of care.
The case managers coordinate care for about 30 to 35 patients a day.
A separate utilization management staff communicate with payers.
"A few of the utilization management staff are RNs. Most are LPNs. They have been trained by the staff over time and enjoy that type of work. They are a good complement to the case managers," Lemons says.
The case managers' hours are staggered and depend on where the need is greatest on that unit. For instance, they start work at 7:30 a.m. on the med-surg units.
"The case managers are on duty at times when they can round with the physicians. If they work with the surgeons, they may come in earlier," Lemons says.
The emergency department case manager coordinates care for patients until they are stabilized and begins the admission status process. ED case managers typically work until 8 p.m.
Each case manager has a walkie-talkie telephone so he or she is easily accessible to the doctors.
"A lot of times, when physicians walk into the building, they call the case managers to meet them," Lemons says.
Social workers cover the building on weekends and take care of patients' crucial discharge needs. Case managers are on call.
Hospital consults with physician advisor
The hospital system uses an outside physician advisor firm to help make a determination of admission status when the case manager has a question.
"We've found that InterQual criteria is adequate about 75% of the time, but sometimes it doesn't tell the nurse what she needs to know to determine the status," she says.
The hospital system has invested in technology to help the case managers do their jobs in a timely and efficient manner, she says.
In addition to a multifunction software package designed specifically for case managers, the hospital system purchased electronic discharge software that the social workers use to identify available beds and place patients.
In a typical scenario, a social worker on one floor would be calling a facility for five beds while another social worker on a different floor was trying to place patients in the same beds.
"The post-acute providers had an opportunity to be more selective about which patients they accepted, and sometimes this didn't meet the hospital's needs very well. Having our staff compete for the same beds and spend a lot of time faxing paperwork was a poor use of professional time," she says.
Electronic discharge software
The electronic discharge software interfaces with the electronic health records and the case management software.
"As the case managers or social workers identify that a patient is likely to go to a nursing home, they can start creating a packet of information on the patient. When the patient is ready for placement, the resource center associate or social worker can click a few buttons and go shopping for a post-acute placement," she says.
The software electronically transmits patient information to facilities that may be able to meet the patient's needs.
The redesign team debated whether to create a separate documentation staff and decided that it would be more effective to design a model in which the case managers focus on getting patients through the system, she says. The separate documentation specialist staff work out of the health information management department.
(For more information, contact: Elizabeth Lemons, RN, MBA, CPHQ, vice president of clinical effectiveness, Saint Thomas Health Services, Nashville, TN, e-mail: firstname.lastname@example.org.)