Hospitalist case managers save money, bed days for IPA

On-site staff help ensure timely discharge

After Sharp Community Medical Group placed its own case managers in hospitals to help the hospitalists manage their patients, overall bed days were reduced by 12%, saving the independent practice association (IPA) about $4 million.

"This doesn't mean we didn't continue to provide the same kind of quality care for our patients. The case managers worked with the hospitalists to ensure that care was provided in a timely manner and that the patients have a safe discharge," says Patti Derouin-Genel, RN, manager for Sharp Community Medical Group.

Sharp Community Medical Group is one of the largest IPAs in California, with more than 400 physicians on the panel and 155,000 commercial and senior members. Three years ago, the physician group contracted with hospitalists to provide in-house case management at hospitals in the Sharp health care system as part of its efforts to better manage patients through the continuum of care, Derouin-Genel says.

"Once a patient is admitted to the hospital, the medical group is dependent on the services of the hospital staff to get the patients discharged efficiently and effectively. Our nurse case managers partner with the hospitalists to manage the care of our patients and move them through the continuum quickly and safely," she says.

Most of the savings were generated by reducing bed days by moving patients to the right level of care, she adds.

While the acute hospital days went down, the skilled nursing facility days increased, but savings were generated by the lower cost for the lower level of care.

"If patients are really sick, they need to be in the hospital, but when they are able to move to another level of care, it's better for them," she adds.

Derouin-Genel was brought on board to help hire and train the staff to support the hospitalists.

In addition to the nurses who team with the hospitalists to focus on the clinical aspects of care, the medical group hired non-clinical staff, called clinical resource coordinators, to handle all the non-clinical issues, such as ordering durable medical equipment and bed placement in post- acute facilities.

The hospitalists, the hospitalist case managers, and the clinical resource coordinators work as a team in each hospital.

Derouin-Genel interviewed more than 100 people for the hospitalist case management and clinical resource coordinator positions.

"The hospital setting is dynamic and fast-paced. It's a complex job, and it takes a special person to fill it," she says.

The program was a collaborative effort of the physicians in the Sharp Medical Group and the hospitalists, Derouin-Genel says.

"When we initiated the program, we visited all of the facilities to outline the details. We stated that we were willing to bring staff nurses into the facilities to help them manage their patients so they could focus on non-managed-care patients and those who are not insured," she says.

The goal is to provide the right care in the right place at the right time and by the right physician, she says.

The hospitalists and hospital's case managers like having someone to help them manage the care of their patients and help plan the discharge needs, adds Karla Ascencio, RN, director of health services for Sharp Community Medical Group

"For instance, hospital case managers are not familiar with the specific contracts the IPA has with post-acute discharge providers. Having our case managers on hand helps them save a lot of time they otherwise would spend looking for details about the patient's benefits," Ascencio says.

The hospitalist case managers follow all of the patients who are part of the IPA and are responsible for utilization review, discharge planning, and ensuring that patients continue to meet criteria for the inpatient stay.

"We do not separate utilization review and case management. Our nurses need to understand everything that is going on with the patient so they can make very astute decisions," Derouin-Genel says.

The case managers round with the hospitalists each morning, review the charts, and discuss the projected discharge plan.

"The physicians and the nurses work as a team, and it is beneficial to everyone. We collaborate closely with the hospitalists, the primary care physicians, the family, and the patient to ensure that patients have a safe discharge and avoid readmission," Ascencio says.

The physician group practice has developed sets of expectations for the case managers to follow in order to provide continuity of care, Derouin-Genel says.

For instance, the case managers educate the patients and families about the inpatient expectations, including the anticipated discharge date, on Day 1.

"Our job is to help the patients and family members understand that we are here to work with them to ensure that the patient is at the appropriate level of care. We begin the discussions early on to prepare them for discharge to the next level of care, whether it's home or a post-acute facility," she says.

The hospitalist case managers work at the hospital and come to the office about once a month for staff meetings.

The number of hospitalist case managers on site at each hospital depends on the size of the facility.

For instance, Sharp Grossmont has 481 licensed beds and is staffed by four hospitalist case managers and two clinical resource coordinators as well as a weekend case management staff.

The case managers are assigned by floor and handle both the commercial patients and the senior population. The case managers typically carry a caseload of 18 to 22 patients at a time.

"We could manage the utilization review with higher caseloads, but we want to do more than that. By keeping the census small, the case managers can spend a lot of time working with the patients and family to get them ready for discharge and educate them on what they need to do after discharge to avoid rehospitalization," Derouin-Genel says.

The clinical resource coordinators assist the case managers in identifying and carrying out the discharge plan.

They meet with the patients and families and conduct an interview to help the hospitalist case manager determine what the patient's discharge needs will be. For instance, they ask if patients have to climb stairs, if they have had a physical therapy consult, or if they feel comfortable using a walker.

When the hospitalist case manager identifies that a patient needs to go to a skilled nursing facility, the clinical resource coordinator takes clinical information provided by the nurse and uses an electronic post-acute referral system to identify potential facilities. The clinical resource coordinators arrange the transfers to post-acute facilities, order durable medical equipment, and set up home health care.

"This works well because it frees up the nurses to handle the clinical needs of the patient. They are skilled clinicians, and our goal is to allow them to focus on clinical issues," Derouin-Genel says.

The hospitalist case managers and clinical resource coordinators follow the hospital processes and policies so they don't disrupt the hospital's flow.

Even though the health care system has an integrated model, the hospitals have their own processes, Ascencio points out.

For instance, utilization review and discharge planning are separate functions in some of the hospitals, but at Sharp Community Medical Group, the case managers are responsible for both.

"We do make it a point to follow hospital processes, especially around documentation, delivery of the Important Message from Medicare, and timely discharge. We don't want to interfere with what the hospital is doing and we don't want the hospital staff to have to follow behind us and re-do what we already have done so it follows their processes and procedures," Ascencio says.

Sharp Community Medical Group uses hospital data to track variances and determine when there are delays in the process, then comes up with process improvement measures.

If the hospitalist nurses encounter glitches that may delay the discharge or disagree with a specialist, they can call on the medical practice medical director or associate medical directors for help.

The medical group team holds an operations meeting monthly with the hospital administration to discuss any issues that come up.

"Communication between the medical group and the hospital staff has been a key to our success. We've spent a lot of time building collaborative relationships. They're all striving for the same thing we are — a safe and successful discharge," Derouin-Genel says.

(For more information, contact: Karla Ascencio, RN, director of health services for Sharp Community Medical Group, e-mail: Karla.Ascencio@sharp.com or Patti Derouin-Genel, RN, manager for Sharp Community Medical Group, e-mail: Patricia.Genel@sharp.com.)