Redesign cuts LOS, reduces denials, improves care

Model integrates case management, social work

A clinical redesign project partnering social work and case management has resulted in a 15% drop in length of stay and a 66% reduction in denials during a period when the average number of cases increased by 24% at Children's National Medical Center in Washington, DC.

"Our denial rate now in terms of total patient days is very low. It's 1.5%. We have reduced our denials because, with our redesigned model and intense focus on moving patients through the plan of care, we have been able to reduce medical unnecessary days," reports Mary Daymont, RN, MSN, CPUR, manager of case management.

New department created

The redesign created the clinical resource management department, combining the previously fragmented utilization management, case management, and social work functions.

Before the redesign, the case managers were under the performance improvement department, utilization was part of medical records, and social workers were in the department of family services.

"Each department had the family at its core, but each had a different vision statement. We didn't have good interdisciplinary teamwork, and discharge planning accountability was variable," says Brenda Shepherd-Vernon, MSW, LICSW, director of social work, child life, language services, and pastoral care.

In 1998, the year before the redesign was implemented, the hospital was facing a tough managed care market and competition from other facilities in the region.

"Denials were way out of control, totaling more than $8 million a year. The managed care payers perceived our facility as providing inefficient and very expensive care," Daymont explains.

High-risk and high-dollar cases were a problem for the hospital. One case that grabbed the attention of management was a patient who accrued more than $1 million in charges but did not meet medical necessity.

When the administration mandated a clinical redesign, the team began looking at ways to improve inpatient care coordination.

Working with Karen Zander, RN, MS, CS, CMAC, FAAN, principal and co-owner of the Center for Case Management in South Natick, MA, the team integrated the case management, utilization management, and social work functions into one cohesive department.

Kathleen Chavanu, the hospital's executive director of quality and clinical support services, led the effort to redesign the hospital's clinical resource management model.

"Our goals were to reduce denials and length of stay, to improve care coordination, to hold all team members accountable, improve our relationship with external payers, and to change their perception of the hospital," Shepherd-Vernon says.

Two case management positions

Under the redesign, there are two case management positions:

• Case Managers I have a bachelor's degree and are responsible for utilization review and denials management, working with the on-site review nurses, interfacing with the health care team and insurance company, and managing reviews of observation and admission status.

• Case Managers II have a master's degree and are responsible for family meetings, discharge planning, and coordination of care while the patient is in the hospital.

A Case Manager II and a social worker are assigned to each unit, typically covering 26 to 28 beds. The exception is the neonatal intensive care unit, with 40 beds.

The team can cover the extra load because the patients have a longer length of stay and there is more time to arrange post-discharge services, Daymont explains.

"We had to educate many of the people in the Case Manager II positions. They were strong clinical nurses and educators but were not familiar with utilization management. We had to educate them to start thinking about resource management," she adds.

Social workers are on site at the hospital from 1 a.m. to 8 a.m., Monday through Friday.

The unit-based social workers are on duty from 8 a.m. to 5 p.m. In addition to their duties on the unit, they respond when called to work with the outpatient services team.

A social worker covers the emergency department from 4:30 p.m. to 1 a.m., responding to trauma codes and handling other issues in the emergency department.

Two social workers split a part-time position, covering the hospital for 10 hours a day on weekends. Working hours for case managers are 8:30 a.m. to 5 p.m., but the Case Manager II staff often work longer. Case Manager IIs are on call for their unit Monday through Friday after hours.

A weekend case manager is on call but comes to the site if the census is high.

To increase communication and facilitate patient care, the hospital implemented interdisciplinary clinical resource management teams that make rounds on all units. The team includes the physician, social worker, case manager, and nurse.

"The rounds were added in after the initial implementation of the program. When we first redesigned the model, we had people who were together on a team but who were engaging in parallel play. There was not a formal process for sharing information, and there was a lot of distrust between the different groups," notes Shepherd-Vernon.

The team holds clinical resource management rounds every day after the physician rounds. The nurses, social workers, and case manager on each unit establish a plan of care for the day and for each patient's stay.

"Everybody leaves the rounds with an understanding of what they have to do that day," adds Daymont.

Goals of the project

The goals of the redesign project were to reduce length of stay and denials and to establish clinical pathways with outcomes.

The department installed a computerized documentation system and developed databases to make it easy to run outcomes reports and analysis.

The unit-based teams focused on looking at denials, how they were being managed, and why they were happening. They provided those data to the clinical resource management team.

"We looked at where the areas of problems were. We can provide information on length of stay by unit and by diagnosis. The high volume diagnoses seemed to be the area where we didn't have a good handle on coordination of care and length of stay," Daymont explains.

The hospital uses the Pediatric Health Information System (PHIS) database — a collection of data from a number of freestanding pediatric academic medical facilities — to benchmark its outcomes.

"If the length of stay was above the PHIS average, it indicated we were not providing efficient services and that was an area where we needed to focus," Daymont continues.

Implementing clinical pathways

Each clinical resource management team chose clinical pathways to implement, ultimately implementing 52 clinical pathways hospitalwide with the goals of facilitating coordination of care and improving length of stay and clinical outcomes.

The hospital's new onset diabetes pathway dramatically reduced the length of stay and improved coordination of care to the point that a large payer contracted with the hospital to be its disease management entity for children with diabetes.

Under the new system, the social workers begin discharge planning at the beginning of the stay, anticipating any psychosocial issues or other problems that could affect the patient and be a barrier to discharge.

"We have become more proactive as opposed to reactive to discharge and family issues as soon as the patient is hospitalized," Shepherd-Vernon says.

The team developed the social work initial assessment and risk tool, a communication tool that clearly states the pertinent information that all team members need to make assessments.

Barriers to discharge are identified

The social work assessment identifies barriers for discharge, providing a clear understanding for all team members what the impact of the patient's condition and hospitalization is likely to be on the family, Shepherd-Vernon says.

"We get an idea from admission what the potential problems may be for the family and document it clearly in the medical record," she adds.

For instance, the social worker may find out that the patient's mother uses a walker and may have a problem taking care of the child upon discharge. The social work assessment communicates this to the case manager, who may not have met the mother.

The department's family service associates assist the social worker and help identify resources needed to plan for the patient and family.

"Families of hospitalized children often have a lot of different things going on in their lives, and we don't always get the correct information at admission. We were spending a lot of time learning about the family and what kind of support they need. This role is critical in helping stretch social work resources," Shepherd-Vernon points out.

The social work team developed a computerized data collection tool to help track how many families they assist and what they do for them.

"We needed to know more about our families and to be able to work with families at a greater level than in the past," she adds.

"This tool helped us compile information about what the staff are actually doing. It also includes readily accessible resource information that helps us move from a passive, traditional social work model to a proactive, efficient, and streamlined work force," Shepherd-Vernon explains.

In 2001, social workers performed an assessment on 26.9% of patients who stay in the hospital 48 hours or more. By 2004, the figure had jumped to 73.9% of patients who are assessed by social workers. The family services associates and the computerized data have enabled the department to increase the figure with the same 10.5 full-time equivalents, Shepherd-Vernon says.

The case management department developed the Interdisciplinary Patient and Family Education and Discharge Planning Record, called the "pink sheet" because it's printed on bright pink paper.

The case managers record discharge planning activities, what has been done, and what the next step is. If the case manager is working with another family or the discharge takes place after hours, the nurse or physician handling the discharge readily can see the plan.

One of the benefits for the entire team with the pink sheet is that it makes clear what needs to happen when patients are discharged," Daymont explains.

"It the patient is discharged after hours or in the evening, the hospital staff have the phone number for the post-acute care provider, what services the patient needs, and the information the agency needs," she adds.

Interdisciplinary review board established

The hospital established an interdisciplinary complex case review board that includes representatives from business operations, legal, admission, financial, as well as social work and case management.

The team meets monthly or twice a month if necessary to review complicated and complex cases and come up with interventions that will help move the patients through continuum.

For instance, the hospital frequently has patients who are on a social hold, waiting for a child protection agency to make the next move.

"In the past, staff who were working directly with the patient got frustrated because they felt that nobody was listening. The complex case review board gives them a forum in which to discuss the options for these patients," explains Shepherd-Vernon.

Since implementation, the hospital has been able to retain 40% of total charges.

"The legal department has been instrumental in having discussions with the legal representation for the District of Columbia Protective Services agency and, in some cases, the family court superior judge," she adds.

"We've had local agencies reimburse us for charges that are being denied because they don't meet medical necessity, thanks to their intervention," Shepherd-Vernon says.