Model decreases LOS, less revenue lost to denials

Physicians receive monthly reports on LOS

By redefining the roles of case managers and social workers and working with physicians on patient throughput and length of stay, Fauquier Hospital in Warrenton, VA, significantly reduced its Medicare length of stay by almost a day and decreased the revenue lost because of denials by medical necessity by 70%.

From January 2009 to June 2009, the average Medicare length of stay was 5.82 days. For the same time period in 2010, the Medicare length of stay was 4.86 days. At the same time, readmissions remained stable at 18.7% in the first half of 2009 and 18.5% in the first half of 2010, reports Pat Gerbracht, BSN, MA, CRA, director of case management and social work.

The hospital consistently experiences less than a 1% denials rate.

"We had three denials in the first 11 months of 2010. If the RN case manager is minding the store, there's no reason to have denials or for patients to stay longer than necessary. Our case managers work closely with the physicians and the rest of the treatment team and check for medical necessity every day," Gerbracht says.

The case management team also prepares a monthly physician long-stay DRG report, focusing on high-volume Medicare DRGs, which shows each physician how his or her data compare to those of his or her peers.

At Fauquier Hospital, case managers and social workers use a sequential model of care. Each discipline has a defined role that makes maximum use of its training and expertise.

The RN case managers are accountable for everything medical that happens during the actual patient stay, including length of stay and quality of care. The social workers are responsible for patient and family assessments and discharge planning.

The RN case managers coordinate care until the patient is nearing discharge, then hand the case off to the social worker.

"We have divided up the work so each discipline does what they do best," Gerbracht says.

When Gerbracht arrived at the hospital in 2009, the case management model varied from unit to unit.

"If every person in the department had been asked to make a list of the tasks they did each day, almost every list probably would have been different. There was no clarity about who was responsible for what, which means there was no accountability," she says.

On many units, both the case managers and the social workers were doing the same job.

Before redesigning the model, the case management team brainstormed to determine what was working well in the department and what wasn't. They spent six weeks developing role definitions and determining how the model would work.

"The meetings resulted in a clear statement from each discipline on what tasks they wanted to own," Gerbracht says.

At Fauquier, case managers review every case every day, making sure that all tests and procedures that have been ordered have occurred, that consultants have seen the patient, and that the treatment team is aware of the results.

The case managers coordinate care for between 18 and 20 patients.

"That's a doable number. We are very detail oriented and look at labs, diet, projected outcomes, and the treatment plan, and we do our own insurance reviews. If the caseload was above 20, it would be very difficult to take care of all the details as thoroughly as we do," says Annette McVicker, RN, BSN, CPUR, case manager for the intensive care and step-down unit.

Case managers can tackle a lot of tasks if they don't have to conduct discharge planning, Gerbracht says.

"When you ask the same person to do discharge planning on a busy unit, they're lucky if they can put a review into the system at the end of the day to meet Medicare and insurance company requirements. They know it should happen, but discharge planning is demanding and can over-run the day," Gerbracht says.

The department has a clinical documentation specialist who handles documentation improvement and physician education. The case managers are responsible for insurance reviews.

"When a case manager takes ownership of the case, he or she is the best person to interface with the insurance company. When the insurance company is teetering about approving another day and I tell them I've spoken with the primary care physician and the consultant and here is what they said, it lends credibility to what I am saying because the reviewer on the other end knows me," McVicker says.

The case managers and social workers meet daily to go over the unit census and plan the patient's stay. Social workers have a caseload of 30 to 35 active cases and work with more than one case manager.

"We review the cases where we are anticipating discharge and determine when the social worker will step in. We want to plan as much as we possibly can so we won't have any delays at the end of the stay," McVicker says.

The case manager on each unit holds a daily bed huddle with the unit director, clinical coordinator, and social worker, McVicker says.

"We plan for discharges, transfers to nursing homes, acute rehab facilities, or long-term acute care hospitals. We look at our bed situation and determine if we can downgrade any patients from the ICU or the step-down unit to a lower level of care," she says.

McVicker typically hands off the case to the social worker 48 hours before the anticipated discharge.

"With complex discharges, we put a lot of preparation on the front end and anticipate a time line," McVicker says.

When a patient is likely to need post-acute care, the social worker collaborates with other clinicians to educate the family. The first person who explains the situation is the doctor.

"The physician's word has the most credibility. They sit down with the family and explain why the level of care is necessary," McVicker says.

The social worker communicates with the patient, the family, and the physician about anticipated discharges. He or she alerts the patient and family as to what time the physician is likely to round and gives them an estimated time that they'll be ready to leave the hospital so the family will be ready to pick the patient up. If the patient doesn't have transportation, the social worker will arrange it.

The new model is extremely popular with the staff, McVicker says.

"As a nurse, I am very clinically minded and clinically focused. I like getting my hands on a case and having the time to make sure the patient has the right medication and consultations early in the stay, that they get the education they need and are ready for discharge in a timely manner. I like to see the progression of the case so that when I hand the patient to the social worker, it's neatly wound up," she says.

The case managers concentrate on ensuring that the patient's care is "front-loaded," that the intensive treatment, consultations, exams, and tests occur during the first one or two days of the stay, resulting in a compact and efficient length of stay.

"Outcomes data and readmissions data show that patients with high-intensity, high-acuity treatment in the early part of the stay have shorter stays, fewer readmissions, and do far better overall than those when they had consultations and treatments gradually," Gerbracht says.

The case managers are on such good terms with the physicians that they feel comfortable suggesting, for example, that the physician order a cardiology consultation early in the stay, she says.

Most of the suggestions are accepted, McVicker says.

"That's the beauty of being floor-based. The physicians know that we are monitoring the case clinically and know what is going on. We're on the floor talking to nursing, dieticians, staff from ancillary departments, and the family, and we are seeing what's going on and the dynamics when the physician is not here," McVicker says.

The department creates a monthly physician long-stay DRG report that includes data on the top 10 to 12 highest-volume DRGs with lengths of stay that exceed the Medicare average length of stay by a full day.

"We also use average length of stay when providing coaching for physicians because the number reflects actual clinical stays across the country," Gerbracht says.

Each physician receives a report of DRGs for which they admit patients. The charts show how the individual physician's length of stay compares to that of every other doctor who admitted patients in that DRG.

The charts are coded with the comparative data blinded so each doctor knows his own statistics but doesn't know which other physician has which data.

The reports are confidential and are mailed monthly to each physician's office. Only Gerbracht and the case management specialist who pull the data know what's in the reports.

After the physicians started receiving the report card, the length of stay slowly began to come down, Gerbracht says.

"Physicians are extremely bright and competitive. There's a significant body of research that indicates that the technique of using blinded data is highly successful. This reporting technique allows a sensitive topic to be discussed respectfully," she adds.

[For more information, contact: Pat Gerbracht, BSN, MA, CRA, director of case management and social work, Fauquier Hospital, e-mail:]