Critical Path Network: Care coordinators work 24/7 to increase efficiency, decrease length of stay
Critical Path Network
Care coordinators work 24/7 to increase efficiency, decrease length of stay
Senior staff nurses, case managers cross-trained for the role
When challenged to increase efficiency and decrease length of stay, a multidisciplinary task force at Mercy St. Vincent's Medical Center in Toledo, OH, made the decision to have case managers on duty on every unit 24 hours a day, seven days a week.
"The entire hospital underwent a transformation project, beginning with coordination of care. We looked at whether we were seeing the patients at the right time and on the right day," says Celine Collins, RN-BC, director of care management.
The hospital eliminated the position of case manager and the position of senior staff nurse and gave the people in those positions the opportunity to apply for the new position of clinical care coordinator.
The clinical care coordinators were hired for either the 7 a.m. to 7 p.m. shift or the 7 p.m. to 7 a.m. shift and rotate weekend staffing.
Mercy St. Vincent is a regional critical care hospital with an average daily census of more than 350 patients. The hospital had 20,246 inpatient admissions and 63,133 emergency department visits in 2008.
In 2008, before the project began, the hospital's overall length of stay was 4.66 days. By December of that year, it had dropped to 4.35 from 4.8 days in March. Year to date in 2009, the average length of stay is 4.29 days.
Before the transformation project began, case managers worked eight hours a day Monday through Friday, with two case managers covering the house on Saturday and no one on Sunday.
"We analyzed what hours of operation case managers should be available to review cases, coordinate care, screen patients for discharge planning, and round with physicians. We started by looking at the patient journey from the time they walk into the door until they go out the door after discharge. The decision was made by a core team that we needed case management 24/7," Collins says.
In addition to case managers who worked eight hours a day, five days a week, the hospital had senior staff nurses on every unit who also were responsible for rounding with physicians, ensuring that lab values were complete and reports available when the doctors came in for their rounds, and doing whatever was needed to support the nurses caring for the patients.
The team decided to designate one person on each shift to be in charge of coordination of care and act as leader of the team and created a new clinical care coordinator position to cover the hospital in 12-hour shifts, 24 hours a day, seven days a week.
The hospital still has the traditional staff supervisor who manages the overall picture determining how many staff are needed on a particular unit, how many on-call staff need to be called in, and where the next trauma bed is available.
"We wanted to remain budget-neutral with our full-time positions and decided that if we needed a care coordinator leading the team around the clock, we had to combine the positions of senior staff nurse and case manager," Collins says.
By adding the number of case managers and the number of senior staff nurses on each unit, the task force came up with enough full-time jobs to fill the slots.
"We looked at a lot of different schedules and looked at how many positions we should have to cover each unit 24 hours a day and allow for vacations, holidays, and sick leave. Some units needed more that others because the census is larger," Collins says.
To ensure that trained staff were available to cover the seven-days-a-week shifts, the department decided to cross-train the clinical care coordinators to be floor nurses when needed.
"We have a core group of people who are skilled enough to perform either job," Collins says.
For instance, one unit may have six clinical care coordinators to cover two 12-hour shifts a day.
"We might need only three to handle the care coordination and the others can do floor nursing," Collins says.
The clinical care coordinators went through three weeks of intense classroom and hands-on training. Three preceptors, who were experienced case managers, assisted Collins with the hands-on training.
One of the aims of the training was to teach nurses to think like case managers and vice versa, Collins says.
"The big piece for the nurses was to learn the utilization management piece of the role and understand how to apply InterQual criteria. As nurses, they cared for people who were sick. As clinical care coordinators, they have to look at the patient in a different way and determine if they are sick enough to remain as inpatients," she says.
The nurses also had to learn to start thinking about discharge the day of admission and not when it's time to go home.
"The nurses on the floor give the instructions an hour before someone goes home. We did a lot of retraining them to think like case managers," she says.
The case managers had to learn how to think like a senior staff nurse and be aware of what is involved with leading the unit for the day.
"The case managers had to be able look at the acuity of the patients and how much staff they would need. They needed to be able to say which bed the next admission would occupy, which patients should be in beds closest to the nursing station, and answer all those questions that the senior staff and charge nurses get," she says.
Documentation improvement and the MS-DRG system also was a big part of the training, Collins says.
"We brought a consultant in after the first three months to reinforce our MS-DRG training. Our plan was to do a lot of intense up-front training and continue to reinforce it each month," she says.
"The role of the clinical care coordinator is consistent regardless of the time of day. We are a trauma center and are getting admissions day and night," Collins says.
Like their counterparts on the other shift, the clinical care coordinators who work the 7 p.m. to 7 a.m. shift review admissions for appropriateness and correct documentation and make sure that appropriate patients receive the care mandated by core measures. They look at what the patient will need after discharge at the time of admission and begin to initiate the discharge plan.
When family members visit in the evening hours, the clinical care coordinator is there to answer questions and start educating the family about the patient's discharge needs.
"Having clinical care coordinators on the unit around the clock gives us a chance to take a proactive approach to discharge planning and get the families to start thinking early about the next level of care," she says.
The hospital also added case managers in the emergency department 24 hours a day, seven days a week to screen admissions for appropriateness.
The initiative represents a change in thinking for the entire organization, Collins says.
"This was a hard concept for the entire organization to grasp. In the past, we were set up to serve ourselves and meet the needs of our schedule. This way, we are coordinating care around the patient during the entire hospital stay," she says.
"Our goal is to have zero errors. We want to get the patients in the right status and the right bed, and to get them discharged at the right time. We put the patient first and know that everything we do is central to the patient in that bed," Collins adds.
(For more information, contact: Celine Collins, RN-BC, director of care management, Mercy St. Vincent Medical Center, e-mail: [email protected].)
When challenged to increase efficiency and decrease length of stay, a multidisciplinary task force at Mercy St. Vincent's Medical Center in Toledo, OH, made the decision to have case managers on duty on every unit 24 hours a day, seven days a week.Subscribe Now for Access
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