Critical Path Network

New care management model cuts LOS, observation days

Clerical tasks eliminated for case managers and social workers

Redesigning the care management model and creating a resource center to free the clinical staff from clerical work has resulted in decreases in length of stay and helped drop denials for clinical reasons to zero at St. Vincent’s Medical Center in Jacksonville, FL.

Overall average length of stay has dropped from 5.56 in fiscal 2002 to 5.0, following the first complete year of the program. Length of stay for fiscal 2001 was 5.35, indicating a rising trend before the program was instituted.

Length of stay for patients with less than a 15-day stay dropped from 4.4 days in fiscal 2002 to 3.9 days in fiscal 2003. Fiscal 2004 averaged 3.8 days.

The number of outliers — patients with complex conditions who stay 15 days or longer — has dropped from 1,495 in 2002 to 1,196 in fiscal 2003.

"The savings have been significant. Our new model increased the departmental FTEs [full-time employees] and operating expenses, but we have reduced lengths of stay and ensured that patients are placed in the right status and into the correct bed type. As a result, we no longer get denials for clinical reasons," says Jamie Zachary, LCSW, the hospital’s director of care management.

Until 2002, the hospital had a traditional model of care management, with social workers handling discharge planning and patient education and utilization review nurses who handled chart review and calling in their reviews to the insurance company. The utilization management nurses had no patient interaction.

The hospital conducted a pilot project on three units in 2001 and rolled out the redesigned model hospitalwide in May 2002.

Under the new model, the social workers and care managers work as a team and are assigned by unit. The care managers see the patients on the floor, perform assessments, and work closely with the floor nurses to try to move the patient through the inpatient process in a timely manner.

They work with ancillary departments to move patients up on the schedule if discharge hinges on getting test results.

"The care managers can identify patients’ discharge planning needs more quickly than the staff nurses and refer them to social work or the appropriate resource," Zachary notes.

Social workers handle complex discharge-planning needs, counseling and support, and end-of-life issues. They also coordinate nursing home placements.

A key component of the redesigned department was the creation of a resource center with staff who assumed clerical functions from the clinical staff, freeing up care managers and social workers to spend additional time with patients.

"One of the pitfalls of our pilot project was that we still had the nurses spending a lot of time on the phone with the insurance companies, and we still had the social workers making referrals to nursing homes. The positions in our resource center eliminate that nonproductive time the clinical staff was spending on clerical duties," she points out.

The resource center is staffed by three payer specialists who handle the telephone contacts with insurance companies and close the loop on obtaining authorizations, a placement specialist who handles referrals to nursing homes, a denials management specialist who oversees the appeal of denials, two staff assistants who handle clerical duties such as copying patient records and calling referrals to home health companies, and a department secretary.

Pulling the clerical duties away from the care managers and social workers was one of the biggest factors in increasing efficiency, Zachary says.

"Anyone in the industry knows that calling an insurance company with a clinical review can take an hour, depending on the number of phone prompts and how often you’re put on hold. In the traditional model, nurses are doing that, and it takes their time away from working with patients or addressing care coordination issues," she points out.

The care management staff like the new arrangement.

Judy Pullen, RN, care manager, who worked under both models, says, "Having the resource center take all that clerical work away gives me time to focus on the patients and their families. I love it because it benefits the patients, the physicians, and the hospital."

In the past, Pullen spent all her time doing utilization management.

"Case management is all about holistic care. When we came together as a care management department, we were able to interact with the patients and families and look at all the dynamics to make sure they are going to be able to go that next step when they go home and get well," she continues.

The care managers and social workers are paired and work effectively within the unit. Each has assigned space on the unit in which they work.

"They are ingrained to the life of the unit and see themselves as part of the unit," Pullen says.

The staff start their day in the care management office, where all clinical staff have desks, then move to the units for the bulk of the day.

"We’ve found it to be a positive arrangement to have an area where all the staff can start and end their day because they do a lot of interacting the first thing in the morning and toward the end of the day. They can bounce ideas off each other and help each other with the complicated cases. They are also a tremendous support for each other, offering assistance as needed," she says.

Since the new model was rolled out, the hospital has cross-trained the social workers and care managers to back up each other in some areas.

"The teams have worked well together, and they back each other up. If one team member is busy and a referral comes in, the other team member can pick up and help out," Pullen adds.

The only exception is that the social workers don’t do clinical review for insurance companies.

The interdisciplinary teams meet once or twice a week and go over the care of all the patients on the unit, Pullen adds. The teams include the care manager, social worker, patient care coordinator from the unit, pastoral care, a physical therapist, the nutritionist, and the pharmacist if needed.

As the care managers and social workers began working under the new model, the department found issues that were occurring frequently and were able to make process changes to eliminate denials.

Under the new model, the care management team worked to cut down on the number of observation days, resulting in a drop from 805 in July 2002 to 750 in October 2002 to 552 in January 2003 to 321 in April 2003.

"We felt that we had too many observation days. We were putting patients in observation when they came out of surgical procedures when they should have been moved into observation only if they met criteria," Zachary says.

For instance, the insurance companies were approving an inpatient stay for patients who had lumbar laminectomies but the physician was checking off the order for observation.

This resulted in a review of all standing orders for post-surgical and emergency department (ED) patients and eliminated standing orders for observation, instead giving physicians a choice of where to place the patients. The hospitals’ post-anesthesia care unit nurses make sure the physicians issue orders for patients to be admitted or place in observation after surgical recovery.

Under the new model, the ED is staffed by care managers from 8 a.m. to midnight. Their goal is to identify whether patients need to be placed in a bed, whether they meet inpatient or observation criteria, and to make sure the patients get to the right level of care. For instance, if a physician writes an order for telemetry, the care manager makes sure the patient meets the requirements for a telemetry bed.

"There is a tremendous benefit to having a care manager in the emergency department making sure patients are in the right bed type and the right status," Zachary explains.

When the design was rolled out, the care managers and social workers initially were assigned to groups of physicians.

"Our intent was that they could work as a team with the physicians," she says.

By the end of the first week, the department realized that assigning care managers and social workers to physicians was not going to work in a 520-bed hospital with 22 different units.

"Not only were my staff running all over the hospital, but the staff on the units were complaining that they didn’t have enough room for five or six members of the care management team to be on the unit at one time. We went back to the unit-based model because it works more efficiently for us," Zachary adds.

Looking at the whole picture

The hospital originally tried the physician-centric model of care to provide continuity in care if patients move from one unit to another during the hospital stay. However, at St. Vincent’s, most of the patients who are moved go from critical care to a lower level of care.

"The care managers in critical care don’t usually work directly with the patients because most of the patients are on a ventilator, so having the same person follow the patient is not necessarily an advantage.

"One of their goals is to identify patients who could move to a lower level of care or an alternative setting. We found that not assigning care managers by unit was a deterrent to what we are trying to accomplish," she says.

As a result of the redesigned model, the hospital’s physicians are seeing case managers as a good resource, Pullen adds.

"Since we are looking at the whole picture and involved in managing the patients’ care, we can bring things to their attention that they might not know about. They’ve become more confident in our abilities and skills," she explains.

In the spring of 2001, the hospital conducted a six-month pilot project on three units, pairing social workers and utilization review nurses to jointly coordinate patient care on the infectious disease unit, general medicine unit, and telemetry unit.

The hospital set and tracked indicators for each unit to measure the outcomes.

For instance, one of the infectious disease indicators was to move patients from IV antibiotics to oral antibiotics in a more timely manner.

"This would be better for the patient, and it would reduce length of stay and reduce our cost," Zachary says.

In the telemetry unit, one of the goals was to move patients from telemetry as quickly as possible.

The care management teams met or exceeded all the indicators in all three units.

After six months, the care management department was able to demonstrate a significant cost savings generated by the pilot project and decrease in length of stay when it was an indicator for a particular population.

After the pilot, Zachary took a proposal to redesign the care management department to the senior leadership, showing how rolling out the new model throughout the hospital would affect the quality of care and utilization of resources.

"My proposal involved using the resources we had and adding some staff. I estimated it would take about 14 months to roll out. Senior leadership liked the model so much and were so impressed by the potential of cost savings that they wanted to roll it out before July 1, 2002, the beginning of our budget year," she says.

The medical center chose a consulting group to help roll out the new arrangement and worked with it to further develop the model. Working with the consulting firm, the department went live with the redesigned care management process in just four months.

The new system was rolled out in mid-May 2002, to give the department some time to work out the kinks before the new fiscal year began July 1.

Hiring people for the new positions was one of the most time-consuming and challenging parts of rolling out the new department, Zachary says.

"We established the job descriptions in the way we thought to be the most efficient and effective," she says.

The existing utilization management nurses had to apply for care management nurse positions because it was a new position.

"We looked for the best possible candidates for those positions. Some chose not to apply, some chose to be interviewed and were not selected. Some interviewed and were selected," she says.

The social workers’ jobs were not new positions so the existing social workers stayed in those positions. All of the resource center positions were new.

"While we were posting the positions and interviewing people, we developed the training program and content," Zachary says.

The three-day training program was for all staff, but at times, the staff were broken into small groups. For instance, only the social workers and placement specialists participated in the nursing home placement component.

Several departments worked with the care management department on education and training, including the managed care, patient accounting, patient access services, information services, nursing, and other ancillary departments.

Following implementation of the new model, feedback from these departments was used to implement other changes or processes.

For example, now representatives from the care management staff meet monthly with the hospital’s biggest payers and quarterly with other payers, discussing issues related to utilization, preauthorization, insurance verification, and payment.

"It’s helped to establish a really good relationship with the payers so we can handle any issues concurrently. We have also established teams to continually evaluate our success dealing with issues such as status change and denials," she says.

[For more information, contact:

  • Jamie Zachary, LCSW, Director, Care Management, St. Vincent’s Medical Center, Jacksonville, FL. Phone: (904) 308-8551. E-mail:]