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Department redesign leads to cuts in LOS
Since North Oaks Health System redesigned its case management program and assigned its RN case managers by physicians, the average length of stay has decreased by a half a day, one-day stays have decreased to within state and national averages, and the readmissions rate has decreased by 43%.
"Denied days historically have been well below 2%. In 2010, they've decreased to about 0.5% of the total patient days. Our patient satisfaction scores consistently have us in the top 20% of hospitals in the nation. The physicians say this is the greatest thing the hospital has ever done for them," adds Sherri Hayes, RN, CCM, assistant vice president of case management at the 269-bed community hospital located in Hammond, LA.
Case managers and social workers were unit-based at the time the hospital started its redesign project in April 2004.
Under the reorganization, the case management umbrella includes acute care case management, emergency department case management, social work, utilization review, bed control, and a clinical documentation improvement program staffed by RN documentation specialists and an inpatient coder. The Recovery Audit Contractor (RAC) program coordinator also is assigned to the case management department.
The care managers are assigned by physician, and each care manager works with between one and five physicians, depending on the doctor's average daily census. They coordinate care for 100% of the patient population, regardless of payer, and assess patients for medical necessity every day.
Social workers are assigned by unit and work as a team with the care manager.
"This arrangement works well because both the care managers and the social workers know their patients well. The social workers can intervene on psychosocial issues and to set up post-acute services. Although one discipline is patient-based and the other is unit-based, there is a lot of gray area and the two disciplines work very well together, accomplishing team goals," Hayes says.
For a brief time, the hospital paired the social workers with the RN care managers, but moving them from unit to unit to implement a discharge plan proved difficult, Hayes says.
"The social worker was faced with working on one case at a time instead of batching work and phone calls. They had to backtrack often, as they would receive a consult shortly after they had left a unit and have to return. Sometimes a difficult discharge plan could have them stuck on one unit all day, forcing them to get a co-worker to check on their other cases," she says.
When the new model first was launched, the RN care managers continued to perform utilization review.
"Logistically, that kept them in the charts more than with patients and physicians. We decided to utilize LPNs in that role with clerical support to help them," she says.
The utilization review staff conduct clinical reviews on patients covered by Medicaid, Medicare Managed Care, and commercial insurance.
Under the new model, case managers and social workers work primarily in the hospital on units, but have a suite of offices adjacent to the hospital. The care managers take cell phones with them on their rounds. The social workers have a computer and a phone with voice mail at their designated nursing units.
"We found that the cell phones improve communication between the care manager, physicians, and other staff because they are moving from unit to unit. This way, no one has to page them and wait for a call back. They can reach them immediately or leave a voice mail," she says.
Each morning, the RN care managers receive a print-out of all their patients, the admitting physician, the admitting diagnosis, the MS-DRG, the estimated length of stay, and any pertinent financial information, along with a notation if the patient has been readmitted within 30 days.
"This information helps the case managers identify which patients they need to see first," she says.
The case managers set their daily routine according to when the physicians they work with make rounds.
The majority round with the physician they're assigned to who has the largest case load. Then they round on their other patients they didn't see on the initial rounds.
"They keep track of the tests ordered for the day, call the physician back with the results, talk to family members, and arrange for consultations. Their focus is to move the patient through the continuum as smoothly as possible. This may mean getting the family together with the physician or talking with an ancillary department," she says.
When patients are readmitted within 30 days, the case managers conduct an in-depth assessment to determine what went wrong, using a tool to determine any contributing factors to the readmission.
The CM conducts an initial review and turns the case over to Hayes or the department coordinator. The administrative team and the medical staff receive reports on the readmission trends.
"If they feel the patient was prematurely discharged, that case goes back to the medical staff for review. If it's an incomplete discharge plan, we identify what we should have done on the previous stay. If noncompliance was an issue, we compile that information as well," she says.
When patients have been discharged after the readmission, the care manager makes a follow-up phone call to ensure they have met their discharge goals, that their prescriptions have been filled, and any needed equipment has arrived. The care manager makes sure patients have a follow-up appointment and answers to any questions or concerns.
All utilization data and delays in services are reported to the administrative team on a monthly basis. The administrative team and the medical staff receive dashboard reports on the average length of stay, readmissions, denied days, and case mix index.
In addition to the normal case management metrics, the administrative team also receives productivity data that include the volume of patients seen, reviews conducted, types of interventions, and other related information.
"We communicate constantly with our nursing department and the ancillary departments to ensure that the patients' needs are met in a timely manner," Hayes says.
"In addition, we communicate with our administrators to make sure they know the return on investment they are getting from this program, not only financially but, equally as important in terms of quality of patient care and physician relations," she adds.
[For more information contact: Sherri Hayes, RN, CCM, assistant vice president of case management, North Oaks Health System, e-mail: firstname.lastname@example.org.]