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Patient intake center operates 24-7
Protocol allows RNs to make admission decision
Every admission to any of the four facilities in the Christus Santa Rosa health system goes through a central patient intake center where RN case managers screen for medical necessity and appropriateness of care and determine patient status.
"We have one central location that services all the facilities and processes every admission, including the transfers. We know up front whether the patient is in observation or to be admitted as an inpatient and whether he or she needs a telemetry, medical-surgical, or intensive care bed," says Roxanne Jenkins, RN, regional director, care management/accreditation compliance for the San Antonio-based health system.
The patient intake center has had a major impact on reducing denials, reducing inappropriate observation status classifications, and assuring appropriate level of care, she adds.
Denials dropped from 3.6% of net patient revenue in fiscal year 2001 to 0.7% in FY 2008. The hospital experienced no denials related to medical necessity in 2007, 2008, or so far this year, Jenkins reports.
The patient intake center is staffed 24 hours a day, 365 days a year by experienced RNs who are trained in admissions criteria. The hospital system uses both InterQual and Milliman criteria to meet the requirements of the complex list of managed care payers in the area.
"We have a large pediatric population as well as Medicaid managed care, and not all payers use the same criteria," Jenkins says.
The patient intake center takes a three-pronged approach. The nurses look for medical necessity for inpatient admissions, whether the patient might meet observation criteria or need outpatient treatment.
The hospital system has developed protocols approved by the medical staff that allow the patient intake center case managers to suggest the admission status using evidence-based criteria. They place the orders on the chart with the approval of the admitting physician and the physician signs them on their next visit.
If patients don't meet acute care admission criteria, the nurses suggest an alternative level of care.
"Our social workers and case managers in the hospital can provide a resource list and contact information for LTACHs, home health, durable medical equipment, or whatever the patient needs," she says.
Before the new system was instituted, hospitals in the area would routinely transfer patients to Santa Rosa if they had no funding sources because of the impression that the hospital was supposed to provide the charity care in the community.
Now hospitals that want to transfer patients to Christus Santa Rosa have to fax clinical information and data to show that the patient needs a higher level of care or service than the transferring facility can provide.
If patients don't need a higher level of care or service, the patient intake center nurses can deny the transfer.
For the first 18 months of the new process, denials of transfers had to go through the administrator on call. The department would follow up the next day with a letter explaining that the patient who was denied a transfer didn't need a higher level of care or service than the transferring hospital could provide.
"In the beginning, we woke up a lot of administrators. Now, when the PIC nurses cannot see the need for our services, they have the authority from the administration to deny a request for a transfer," she says.
Before the patient intake center was opened, nurses and office managers from physician offices might call the admission office, the nursing supervisor, or the nurse managers on the floor to get a patient admitted. Sometimes, patients would show up in the emergency department saying their doctor told them they were being admitted and no one in the hospital was aware of it.
"There was a lack of organization for the admission process," she says.
Now the physician's office staff have just one number to call. They fax in the patient's clinical information to the PIC nurse who screens the patient for admission criteria.
The patient's registration information already is in the hospital computer system when he or she arrives.
When a patient presents to the emergency department, he or she is triaged and treated by the emergency department physician, who notifies the patient intake center if an admission is required. The nurses can access all the clinical data on the computer and make a decision on whether the patient meets admission criteria. The PIC nurse reviews the data for the admission, based on criteria for medical necessity.
"The PIC continues to serve Christus Santa Rosa's four facilities and will soon expand to five," Jenkins says.