Education was key to success of CM protocol

Research also critical

Before developing a protocol that delegates authority for determining patient status to case managers, a multidisciplinary team at Good Samaritan Hospital in Dayton, OH, spent several months researching the process, seeking advice from the Florida Quality Improvement Organization (QIO) and hospitals in Florida that had piloted a case management admission status protocol.

The hospital's integrated care management status team also worked closely with its QIO, Ohio KePro, and invited its representatives to participate at meetings and conference calls. The agency was involved in every step of the development, says Teresa I. Gonzalvo, RN, MPA, CPHQ, LNC, director of integrated care management.

"Like most hospitals, we have an ongoing challenge of determining whether patients should be admitted as inpatients or placed in observation status," she says.

The hospital's integrated care management department has partnered with a sister hospital, Miami Valley Hospital, on a project to establish the infrastructure for a case manager dedicated to observation patient reviews, tracking and trending charges and missed opportunities.

"The project showed overall improvement and modest gains. With Medicare's increased emphasis on medical necessity and the anticipated rollout of the Recovery Audit Contractors, we knew we had to do more to ensure that every patient is placed in the proper status," she adds.

It has long been a challenge to get physicians to assign the proper status to patients, says Donald P. Sickler, MD, medical director for integrated case management.

"It is necessary to know the diagnosis and treatment to assign status but it's not necessary to know the status to diagnose and treat a patient; therefore, many physicians consider it a nuisance and put as little effort as possible into the process," he points out.

Before the project was implemented, patient status was, at best, educated guesswork by the physician, with the case manager working to get it correct during the hospital stay, says Daniel L. Schoulties, MD, vice president for medical affairs.

Many physicians were not familiar with InterQual criteria at the time, he adds.

Rather than training the medical staff on those criteria and expecting them to use them properly and objectively, it made more sense to allow case managers who use InterQual criteria daily to assign the patient status with support from the physicians, Sickler says.

The team began by educating the medical executive committee about admission status and the importance of getting it right.

"It is important that everybody involved with patient care knows how status is assigned and the ramifications of placing a patient in the wrong status," Sickler says.

The medical executive committee voted to have the patient status assignment delegated to the case managers. However, initially, some members of the executive committee were uncomfortable with having a case manager assign the status without a physician signature, Sickler says.

"Since the physicians had already signed an order on the chart delegating the responsibility for admission status determination to the case manager, we decided that it was redundant to ask them to sign off on the specific status assignment the second time," he says.

The team looked at the various parts of the admissions process, such as what forms were being used and which ones needed to be changed or what needed to be developed.

They modified the preassembled bed assignment forms and order set packages to be used in the emergency department for status determination.

The team created a case management status sheet that goes into the medical records. The sheet, which is signed by the case manager, includes the date and time the patient is placed in inpatient or observation status followed by check-off boxes for the rationale for the status assignment.

For instance, there are boxes for the case manager to check off if the patient meets InterQual criteria; if a surgical procedure is on Medicare's inpatient-only list; if the patient failed outpatient treatment; if the patient has complications or comorbidities that complicates his or her care; or if the patient is at increased risk for a significant clinical event. There is a space for the case manager to add details, such as the name of the procedure or complication, when appropriate.

Under observation status, the case manager checks off if the patient meets the InterQual criteria for observation, if the patient does not trigger the inpatient criteria, or if Condition Code 44 is being used.

The team involved all areas of the hospital in the project including the post-anesthesia care unit, surgery scheduling, the referrals management center, direct admissions, the family birth center, the cardiac catheterization laboratory, mental health, insurance verification, patient access, and all patient units.

"For us, communication was the key in rolling out the process. Every department was affected by the change, so it was critical to bring in all the stakeholders and educate them," says John W. Clark, RN, BSN, manager, case management.

The team spoke at every nursing staff meeting at every unit in the hospital.

"We wanted all the key stakeholders from other departments to know what we were doing and the reason why," he says.

Before the project went live, the hospital made sure that all case managers were proficient with InterQual criteria. They instituted additional training on scenarios that can affect admission status, such as comorbidities or failure to improve with outpatient treatment.

"We practiced with difficult cases. Once we went live, we performed our own audits and requested an audit from Ohio KePro," Sickler says.