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A new on-line reservations and booking system is streamlining the discharge process at New York Hospital of Queens in Flushing, where case managers are using the software tool to determine the availability of post-acute services, then request and schedule those services over the Internet.
The system has broad implications for access managers, who can use it to identify a patient who is at risk and automatically trigger a referral to the case manager.
Since implementing eDischarge, a product of Needham, MA-based Curaspan Inc., in mid- January 2002, staff dramatically has reduced time spent on the telephone, enhanced the quality of report writing, and are able to make more precise matches of patients with care facilities, says Caroline Keane, RN, MSN, ANP, CCM, director of case management and social work.
Access managers can use the system both to get information on past admissions — which can be particularly helpful with patients who are "frequent admitters" — and for on-line authorizations from third-party payers, notes Jackie Birmingham, RN, MS, CMAC, managing director for professional services at Curaspan.
"When admitting the patient, it’s good to have a history of where the person is admitted from," Birmingham says. "It’s a closing of the loop between access and case management."
The system has a portal, she notes, which can be used to send patient information to payers and receive on-line authorization for services. "The [request for authorization] can go over this secure site and can electronically beep’ the payer." (To see eDischarge image, click here.)
Communication with payers is enhanced, Keane says, in that her staff can take a list of all the facilities within a certain plan and electronically transfer the patient review instrument (PRI) and other information in real time. "We don’t have to find a fax machine and fax to five different facilities."
Then, she adds, "we can make one phone call to a managed care company and say, This patient has been medically approved by one of your preferred providers. Can I get an authorization number?’"
"It’s real-time," explains Keane. "We used to send out PRIs — maybe a 20-page package — to five facilities via fax. Even though it was programmed into the fax machine, it took a lot of effort, and then maybe it didn’t go out right. Now we put in one [PRI] and send it out to all five at once. The PRIs are much more legible."
The high-quality reports alone are a huge plus to her operation, Keane says. But Columbia Presbyterian, the network to which her hospital belongs, chose to implement eDischarge in large part because of the patient privacy protection it provides, she notes.
With the privacy regulations of the Health Insurance Portability and Accountability Act becoming effective in April 2003, Keane adds, "we’re looking toward the future. This is an encrypted system, a secure system. We decide how much information the person on the other side receives, and at what time we give it."
As part of the eDischarge process, post-acute providers that take referrals from the hospital, including skilled nursing facilities, home health services, and rehabilitation facilities, complete a profile outlining the services they offer. Each day, the provider updates the bed or service availability.
At her hospital, Keane explains, there is a merged case management/social work department, with 19 registered nurse case managers, seven social workers, and one placement coordinator, who acts as a liaison between the post-acute facilities and the social workers. The hospital has about 460 patients at any one time, she says, and her department arranges between 200 and 220 nursing home placements patients per month.
The case manager drives the discharge plan, Keane says, determining whether the patient should be placed in a facility or cared for at home, doing the initial intervention with the patient’s family, and performing the ongoing chart review.
Once the discharge plan is firmed up, and there is a solid placement need, the case manager makes a referral to the social worker, Keane says. "The case manager continues to review the case, and as the patient becomes closer to discharge-ready,’ issues the PRI, entering it electronically into the computer."
Meanwhile, she adds, the social worker has developed a relationship with the family, helping them understand the process and negotiating where the patient will receive post-hospital care.
When the patient is ready for discharge and the PRI is completed, the case manager transfers it to the social worker, who completes the departmental screen of the patient and transfers the case to the placement coordinator with a list of appropriate facilities, Keane says. "The placement coordinator electronically sends out queries to facilities the patient and family have chosen, and awaits the follow-up. When she gets that, she transfers the information appropriately. If there is a medical need or question, it goes to the case manager, but if there is a financial or psychosocial need, it goes to the social worker."
Once the patient is accepted by the facility, she notes, the PRI is updated, if necessary, and the social worker proceeds with the transfer. If the patient came from a nursing home and is returning there, the process is driven by the case manager from start to finish, and there might not be a social worker involved, Keane adds.
To protect patient confidentiality, identifying information on the patient is sent to the provider only after the final match is made, she notes. "We can give [the provider] just a look at the PRI and whatever clinical information is necessary. We’re not giving them next of kin until we’re ready to give them next of kin, and we’re not using fax lines that may not be secure."
The eDischarge system "eliminates the back-and-forth," Keane points out. "Otherwise, people are going back and forth, faxing within the building, going up and down [floors] all day. We’ve decreased the unnecessary steps."
A clerical employee, for example, used to spend five hours collecting data and typing and distributing a monthly report showing where patients have been placed, she says. "The system does it in a minute, and we run a great report at the end of the business day."
Her staff can look at data showing where a patient was placed, how many facilities were sent applications, and what facilities have taken what types of patients in the past, Keane adds.
Using the criteria match that is part of eDischarge, case managers sometimes are able to find an appropriate placement for patients they didn’t think a facility could accommodate, she points out. "We’d look at the criteria match and say, Oh, we didn’t know they did dialysis,’ so it was a heads-up that a facility we didn’t think about would take a patient."
Placement of people with extreme needs, such as a recent 540-pound patient, also is facilitated by the on-line system, Keane says. "We can query [regarding] specific patients who have specific needs to see if a facility we don’t use very often can provide that service.
"You know the facilities in your area that you use all the time," she adds, "but occasionally a facility is changing its scope of practice or opening a new unit. It’s right there on the computer."
An important point to remember, Keane points out, is that the on-line discharge system by necessity must "change the way you do business. You have to set a limit [on telephone calls], squelch that knee-jerk impulse to use the phone."
Although cases already are being turned around and decisions being made more quickly, she says, Keane expects further improvements as her staff gets more comfortable with the system. "We’ve created our own security measures, but as time goes by we’ll drop some of the unnecessary [backup] steps and will get faster."
"Any time there’s a change," she adds, "there’s always a little holding on to the past, but the future is where you need to be."