New hospital uses tried-and-true CM practices

Collaborative approach includes daily rounds

Daily multidisciplinary rounds, a full-time medical director who is part of the clinical resource management team, and a clinical resource manager who acts as an additional resource for the case managers on the floor were chosen carefully to promote better patient care when the case management model was developed at the new Memorial Hospital Miramar (FL).

Although the 128-bed community hospital, which opened in March, doesn't have enough data for definitive outcomes, so far staff have been successful meeting the CMS Quality Indicators, keeping avoidable days to a minimum, and earning high scores for discharge planning on patient satisfaction surveys, says Patricia Wilds, RN, BSN, CCM, director of clinical resource management.

The hospital, part of Memorial Healthcare System in South Broward County, FL, based its integrated CM model on tried-and-true practices from the other hospitals in the system.

"The case management model has been ongoing at other facilities in the health system and has evolved over the past four to five years. It includes the director of clinical resource management and the clinical resource manager, and a physician. Bringing a physician on board to direct the process is something the entire system started doing several years ago," reports Eric Freling, MD, director of medical affairs for the hospital.

The clinical resource management team at Memorial Hospital Miramar includes six RN case managers, one full-time master's-prepared social worker, Wilds, the director, and Anna Carter, RN, MS, manager of clinical resource management.

The case managers and social worker stagger their arrival time to cover the hospital from 7:30 a.m. to 6 p.m. They rotate being in the hospital for eight hours a day on Saturdays and Sundays and on call 24 hours a day. Case management duties include utilization review, discharge planning, screening, resource consumption management, and patient education.

A case manager staffs the emergency department Monday through Friday, screening to make sure patients meet admission criteria, starting the discharge planning if patients need it, and initiating some of the protocols for the core measures.

Carter's role is to be an extra resource for the case managers on the floor and the admissions nurse. In addition to attending the daily rounds, she monitors the discharge planning process and double-checks to makes sure everything is in place when it's time for the patient to go home.

"The case managers call me when they're not sure if the patient meets the InterQual criteria. I identify any high-risk and high-cost patient and assist in ensuring that they are getting the care they need in a timely manner," she says.

Freling is an integral part of the clinical resource management team and spends 50% of his time working with them to make sure patients meet criteria and helping move them through the continuum of care, a role that Wilds and the rest of her staff welcomes.

"Since this is a new hospital, many of us came from other facilities where we didn't have a medical director or physician advisor who devotes so much time to the program. We have found it to be very helpful in providing top-quality patient care and moving patients through the continuum as quickly and safely as possible," Wilds says.

Daily rounds

Daily rounds on all patients by a multidisciplinary team are a key component of the hospital's collaborative approach to patient care. A core team, which attends daily rounds on all units, includes Wilds and Freling, along with representatives from dietary, physical therapy, pharmacy, and infection control.

The core team moves from unit to unit, attending rounds on all patients every day with the nurses and case managers assigned to that particular unit. The hospital's chief financial officer accompanies the team on rounds as a way of finding out what is going on in the hospital.

"She's very receptive to learning about the medical processes and how the case management department works. This is an asset to our department because we have support from the administration," Freling says.

The team looks at the patient's diagnosis and demographic information, progression of care, where the patient is in the continuum, whether the treatment is following standards of care, and makes sure the core measures are being followed, if applicable.

"Our walking daily rounds emphasize team management of patients. We talk about the progress of the patient, based on their diagnosis and symptoms and make sure the standard of care for that diagnosis is being followed," Carter explains. For instance, the pharmacist may make sure the antibiotic prescribed is appropriate for the diagnosis, or the dietitian may determine whether a stroke patient needs a swallowing evaluation.

"We look at the patient's age and social issues, discharge plans for the patient, and what we need to do, so that when they become stable from a medical standpoint, they'll be ready to go home," Wilds says. For example, if the patient needs a dietary consultation or labs before discharge, the team facilitates that taking place.

"We look at whether these services could be done in another setting and look every day at the level of care to see if the patient is ready to be moved through the continuum," Carter says.

If the patient needs a test to be discharged and the schedule is full, Freling talks to the department head to make sure the test gets done.

When the team conducts rounds on the intensive care and telemetry units, it looks at whether the patient can be weaned from the vent or the drip, and whether there are end-of-life issues or reasons to call a family conference on the patient's condition. "We are very proactive. If we see something that needs to be done, we assign a member of the team to call the physician," Freling says.

The team has found it useful for the nurses who care for the patient to accompany them on rounds. "Sometimes, they have an emergency and can't give us information. When they can be there and give us a report and talk about the case, it helps us come up with ideas about how to best manage the patient's care," he adds.

For instance, the team may suggest to the nurse ideas to discuss with the physician, such as a need for wound care or physical therapy or a dietary consultation. "When the nurse is right there and involved, the result is more efficient patient care," Freling says. If the case managers are having trouble getting documentation or ensuring that the CMS Quality Indicators are in place, they can call on Freling to intervene with the physician.

Attending physicians find the clinical resource management team a valuable resource that helps them coordinate their patients' care and make sure that tests and other procedures are carried out in a timely manner, he says.

"This team gives us the ability to have an overview from 30,000 feet of what is going on with the case. We can make suggestions when something might have been overlooked, allowing interventions to be made in a more timely manner so discharge planning can move ahead more quickly," Freling adds.

An admissions nurse reviews all the patients who are admitted to the hospital and handles preauthorization and screening for InterQual criteria. The admissions nurse is part of the admitting and registration department and works closely with the clinical resource management team to ensure that all patients meet criteria for being in the hospital.

"There is ongoing communication between the admissions nurse and the case manager on the unit. We are always looking at criteria and getting the clinical information needed to document that the patient meets criteria," Wilds says.

For instance, if a patient with congestive heart failure comes into the hospital as a direct, the admissions nurse asks the admitting physician if he would like to use the standing order sets for congestive heart failure and then initiate them. The emergency department case manager will do the same if the patient comes in through the emergency department.

Both communicate with the case manager as well as the nurse on the unit that the patient is coming and that they should begin implementation of the orders when the patient arrives.

The admissions nurse applies InterQual criteria for severity of illness and intensity of service based on information given by the physician's office or the emergency department.

If more information is needed, such as a chest X-ray performed in the doctor's office or further documentation, the admissions nurse gets in touch with the physician's office. The resource management team does the follow-up review the next day during the daily rounds.

"Because there is constant communication between the admissions nurse and the case manager on the floor, we've been successful in obtaining the documentation needed to ensure that the patients meet criteria," Wilds says.

During rounds, the team makes sure that the patients meet criteria for continuing to stay. If the patient does not meet InterQual criteria, the case manager calls the physician to ask for additional information and to talk about whether the patient is stable enough to be discharged.

If the physician doesn't have additional information or is resistant to discharge, Freling gets in touch with the physician and makes sure the documentation is in place or plans are made for the patient to be discharged.

Having a physician on the clinical resource management team is an asset to the success of the department, Wilds says.

"He adds credibility to what we are saying and can clarify our concerns from a medical standpoint. It's a great advantage to have him on the team," she adds.