Critical Path Network: Review of one-day stays improves documentation
Review of one-day stays improves documentation
Supervisors look for opportunities for improvement
At Sutter Health's Sacramento (CA) Sierra Region, case manager supervisors at each hospital conduct a secondary, retrospective review of 100% of one-day stays of Medicare patients to ensure that the individual case managers are making the right determination and using any deficits they uncover as an educational opportunity.
The system has significantly improved the accuracy of the case managers' reviews, says Michael Avriette, utilization management executive for the seven-hospital region of Sutter Health, with headquarters in Sacramento.
"We concentrate on one-day stays because they are the most at risk for not meeting medical necessity criteria. In addition, we don't have that many and they are easy to track," he says.
In addition, the review of one-day stays gives the case management supervisor a good indication of how accurate the case manager is likely to be on other cases, he adds. "If people know that a particular kind of case is going to be reviewed and they still have a lower-than-average accuracy rate than their peers, it's probable that their accuracy is lower than average on other cases, as well, and that they need additional education on medical necessity criteria," Avriette says.
Each hospital's software system automatically populates a work list of one-day stays of Medicare patients for the case management manager to review each day.
The manager reviews the case manager's documentation in the software and, if necessary, reviews the medical records as well to determine if the case manager made the right decision.
"If the manager finds that a one-day stay doesn't meet admission criteria, he or she looks at where the opportunity for improvement occurs and determines if it is an educational opportunity or a performance management opportunity," Avriette says.
The manager then works with the individual case managers to educate them on why the patient should not have been admitted for inpatient care.
An example of a performance management improvement is if a case manager qualifies the inpatient admission of a patient with dyspnea when his oxygen saturation is 90%. InterQual criteria specify that in order for dyspnea patients to meet acute care criteria, their oxygen saturation has to be less than 89%. "Sometimes case managers feel pressured not to have a conversation with a doctor about admitting a patient. In this case, if the oxygen saturation was 90%, the case manager might fudge and let the admission go unchallenged but the patient clearly doesn't meet admission criteria. The director educates them that they have to follow criteria," he says.
An example of an educational opportunity might occur if a case manager qualifies an inpatient admission for a patient with syncope and hypertension. "Patients with syncope qualify for an inpatient stay if they have a cardiac disease, and it's debatable as to whether hypertension would count. This would be an honest mistake," Avriette says.
The case management director checks off if the review showed that the case manager made the right call. If the stay was not appropriate, then he or she documents the action taken.
The results of the reviews of one-day stays go into the system in which Avriette generates monthly reports to determine how accurate each hospital's case managers are.
At Sutter Health's Sacramento (CA) Sierra Region, case manager supervisors at each hospital conduct a secondary, retrospective review of 100% of one-day stays of Medicare patients to ensure that the individual case managers are making the right determination and using any deficits they uncover as an educational opportunity.Subscribe Now for Access
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