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Revamp puts case management in control of hospital beds
Aim is maximum reimbursement for ED, surgical patients
When the administration at Davis Memorial Hospital in Elkins, WV, redesigned its case management department, improving reimbursement for emergency department (ED) patients and same-day-surgery patients was a major goal.
"We didn't have anyone covering major surgery or admissions to help us avoid problems up front. We were having inappropriate admissions and social admissions of patients who came through the emergency department," says Tod Thorpe, RN, CPC-H, director of case management for the 90-bed facility in rural West Virginia.
The hospital administration took a close look at the outpatient area to figure out where and why reimbursement problems were occurring.
When the revamp was begun in 2000, some of the staff were handling traditional utilization review, while the rest were discharge planners. The hospital shifted to an integrated case management model, cross-training staff to handle both processes.
The hospital has six case managers on the inpatient side and one outpatient case manager.
"It was easy to integrate the inpatient side. The case managers were cross-trained and unit-based. Each was assigned to a block of rooms," Thorpe says.
The inpatient case managers have a caseload of up to 27 patients and work four 10-hour shifts a week.
Redesigning case management for the outpatient side was a bigger challenge, he says. At the time, the outpatient case manager worked from 2 p.m. to 10 p.m., mostly in the ED, and focused on utilization review, picking up where the day case managers left off.
The case management staff did a needs assessment and shifted to 10-hour shifts, 7 a.m. to 5:30 p.m.
"The chief operating officer and chief financial officer were involved in the process from the beginning. We want to tie the clinical and the financial picture together," Thorpe says.
They identified the areas they wanted to cover: the ED, day surgery, and preadmission for major surgery.
"We wanted bed control. Now any admission from 7 a.m. to 5 p.m. goes through case management before a bed is assigned," he says.
The decision and the announcement to shift the bed control to case management had to come from the administration, because the rest of the hospital staff didn't want to lose control, he adds.
"We looked it at this way: If we [the case managers] are going to get optimum reimbursement and get patients in the right bed, we needed some control [over admissions]," he says.
Now any admission that comes into the hospital from 7 a.m. to 5 p.m. goes through case management. Case managers check for medical necessity and makes sure the diagnosis is appropriate for the admission.
The outpatient case manager covers the ED, day surgery, and pre-admissions. In the ED, she screens admissions and works with the ED charge nurse on any discharge planning needs, such as payer requirements and arranging for durable medical equipment.
In the day surgery area, she reviews the schedule each morning, looking for any potential reimbursement problems and making sure all admitted patients are admitted appropriately.
For instance, she makes sure that if a physician admits a patient for an observation bed, the admission will still be reimbursed. "The patients get the same care regardless, but the reimbursement often depends on whether the physician orders the patient admitted for observation vs. admitted to a room," Thorpe says.
In cases where there may be a reimbursement problem, the case manager works with the physicians to make sure the orders are appropriate and documentation is complete.
"This is where bed control helps. It's hard to measure how many we catch, but the case managers do make sure the orders are appropriate to ensure that we get the appropriate reimbursement," he says.
The outpatient case manager is in charge of preadmission for major surgery.
If the patient is scheduled for a major procedure, the case manager does a preadmission screening, talks to the patient about the surgery, and determines the patient's discharge needs.
On an average day, the ED case manager handles 10 to 15 admissions and screens the majority of them. The process allows the hospital to start discharge planning earlier.
In the past, case managers would be unlikely to see patients until the day after admission, and surgical patients didn't see a case manager until after surgery.
"Sometimes patients would come through surgery and never be seen by a case manager. The new system improves that as well," Thorpe says.
All the case managers have been trained in assigning diagnosis-related groups.
"They have a good understanding of reimbursement and assigning codes, and that helps," Thorpe says.
The case managers who work in the outpatient setting have taken a proactive approach to "social admissions" - patients that the physicians want admitted because they have no other place to go. They work on transportation, home health, and other resources that allow the patients to be safely discharged from the ED.
"It used to be that if the emergency department staff had a problem with someone's discharge, they would put them in the hospital until someone had time to find the resources for them," Thorpe says.
At every staff meeting, Thorpe invites a vendor such as a nursing home, the respiratory association, or a senior service center to come in and talk to the staff about changes in policy, admission requirements, and what services they can provide.
"It's made my staff more aware of what is available out there. It's easier to pick up the phone and ask someone for help if you know their face," he adds.